Financing TB control
The financial analyses included in this report are based on data from 90 countries that together account for 90% of the global TB incidence, including all 22 HBCs and 84 of the countries considered in the Global Plan. These data show that NTP budgets in the 22 HBCs have increased substantially over the past six years, from just over US$ 500 million in 2002 to US$ 1.25 billion in 2007, while total costs (NTP budgets plus the cost of general health system staff and infrastructure used for the treatment of TB patients) have risen from US$ 644 million in 2002 to US$ 1.65 billion in 2007. When all 90 countries are considered, NTP budgets for 2007 amount to US$ 1.65 billion, with total costs of US$ 2.3 billion. In response to these growing budgets, funding for TB control has also increased, from US$ 644 million in 2002 to US$ 1.4 billion in 2007 in HBCs. Nonetheless, funding gaps reported by countries in 2007 amount to US$ 307 million, of which US$ 251 million is accounted for by the 22 HBCs. Moreover, despite increases in planned costs and available funding for TB control since 2002, these funding gaps would be larger still if country plans and assessments of funding requirements were in line with the Global Plan. For the 84 countries for which an assessment could be made, the Global Plan indicates that US$ 3.1 billion is required in 2007, compared with planned costs based on country reports of US$ 2.3 billion and available funding of US$ 2.0 billion. Figures for the 22 HBCs specifically are US$ 2.2 billion, US$ 1.7 billion and US$ 1.4 billion, respectively. The discrepancy is mostly explained by the higher costs for collaborative TB/HIV activities and ACSM that are included in the Global Plan (US$ 832 million in the Global Plan compared with US$ 128 million in country reports), especially in the African and South-East Asia regions.
National budgets compared with the Global Plan
The Global Plan has set out what needs to be done to achieve the MDG and related Stop TB Partnership targets for TB control set for 2015. For this reason, it is important to understand why there are differences between country reports and the Global Plan.
For collaborative TB/HIV activities, the big difference between the Global Plan and NTP country reports has two possible explanations. The first is that the budgets reported by NTPs exclude national AIDS programme budgets for collaborative TB/HIV activities, as well as funding channelled through other mechanisms (e.g. via NGOs). For items such as ART for HIV-positive TB patients, these amounts could be large. The second is that the scale at which implementation of collaborative TB/HIV activities is planned is much less than described in the Global Plan.
The process of clarification and verification of the financial data reported by NTPs clearly demonstrated that NTP budgets do not include all of the budgets and funding available for collaborative TB/HIV activities in some countries. Kenya and India are two good examples. Planning for collaborative TB/HIV activities in Kenya is in line with and sometimes ahead of the Global Plan (for example, 57% of TB patients were tested for HIV in the first half of 2006 with a target of reaching 85% by the end of 2006, compared with the figure of 47% included in the Global Plan for 2006 as a whole). However, the NTP budget is lower than the funding requirements set out in the Global Plan because US$ 7 million is being channelled through NGOs rather than the NTP, and the budget for antiretroviral drugs is part of the national AIDS programme budget (see Annex 1). In India, the only collaborative TB/HIV activity included in the NTP budget is HIV testing of TB patients, which is among the least expensive of the 12 recommended activities. The extent to which other activities are budgeted for and funded by the national AIDS programme is not known.
While NTP budgets are therefore undoubtedly an underestimate of total budgets and funding for collaborative TB/HIV activities, the figures presented in the TB/HIV sections of this report also show that, compared with the Global Plan, there is a large deficit in actual implementation in 2005 as well as in the planned level of implementation in 2006–2007. For example, country reports indicate plans to enrol about 80 000 HIV-positive TB patients on ART in 2006, which is 36% of the 220 000 proposed in the Global Plan. This means that the financing data, in which budgets reported by NTPs are about 10% of those included in the Global Plan, illustrate, but also overstate, a real deficit in both funding and implementation. If ART is considered a good marker for collaborative TB/HIV activities as a whole, then planned budgets for collaborative TB/HIV activities are about one-third rather than one-tenth of the total set out in the Global Plan.
In the case of ACSM, Global Plan estimates of funding requirements were based on a limited number of countries that had developed detailed ACSM plans in the context of applications for GFATM funding in round 5, with guidance from the Stop TB Partnership’s ACSM secretariat. Funding requirements in other countries were extrapolated from this set of countries. Given that ACSM is a relatively new area for most NTPs, and that country-specific data were not available in most cases, it is not surprising that budgets reported by countries tend to be comparatively small.
In contrast to TB/HIV and ACSM, the funding available for MDR-TB treatment is higher than the requirement set out in the Global Plan. This is mostly due to the large budgets reported by the Russian Federation and South Africa; the combined total (US$ 134 million) for these two countries is higher than the US$ 129 million included in the Global Plan for the 84 countries that we were able to analyse for this report. The data for these two countries conceal the fact that budgets, as well as the planned number of patients to be enrolled on treatment, are lower than Global Plan expectations in many countries, including the two with the largest estimated number of cases (China and India).
These differences highlight a need for better alignment between country plans and budgets and the Global Plan. The existing evidence already demonstrates that this has been achieved in some countries – notable examples being Brazil, Kenya, the Philippines, Viet Nam and, with the exception of MDR-TB treatment, China. However, these countries remain a small minority.
If the 2015 targets are to be achieved, robust country-owned plans that include implementation of all components of the Stop TB Strategy at a scale consistent with the Global Plan are needed. In this context, WHO has developed a tool for planning and budgeting in line with the Global Plan and the Stop TB strategy at country level.1 The tool was field-tested in a range of countries in 2006, and an early version was used to help develop strategic plans in Afghanistan and Brazil. The first major use of the final version will be as part of a planning and budgeting workshop for 15 priority African countries including all nine HBCs in the region, scheduled for the first half of 2007. The tool will be used to help develop strategic plans and budgets in priority countries in the European Region during the same period.
Financing the Global Plan
Country plans that are in line with the Global Plan will have larger funding requirements and larger funding gaps, as illustrated by our comparisons with the Global Plan for 84 countries and by specific examples such as Kenya. Filling these funding gaps will require intensive resource mobilization. External grant funding among the 84 countries that we could compare with the Global Plan reaches about US$ 300 million in 2007, with GFATM grants now in place in almost all of these countries and other grant funding stable during the period 2002–2007. Filling the likely funding gap of over US$ 1 billion in 2007 is equivalent to an almost four-fold increase in grant financing. Existing domestic funding, including loans, is about US$ 1.7 billion in 2007; filling the likely gap of around US$ 1.1 billion would therefore need an increase of approximately 65% in existing domestic funding. These figures show that it is unlikely that the funding gap will be filled by donor agencies, and that domestic financing from national governments will be crucial.
Increasing domestic financing for TB control means a major shift from trends during the period 2002–2007, when almost all of the increase in domestic funding among the 22 HBCs was accounted for by three countries (China, the Russian Federation and South Africa). Data from HBCs show that while there is a clear relationship between a country’s national income (measured as GNI per capita) and the share of funding for TB control that is provided by HBC governments, two countries with similar levels of income and burden of TB can have very different levels of domestic funding for TB control. This implies that there is real scope for increasing domestic funding in several countries including Indonesia (compared with the Philippines), Pakistan (compared with India), and Kenya (compared with several low-income countries). There should also be potential for increasing loan funding. In 2007, World Bank loans for TB control in the 22 HBCs are restricted to China, India and the Russian Federation.
Broader trends in funding for the health sector also offer an opportunity to increase domestic funding for TB control in India, to support the management of TB/HIV and MDR-TB, and to expand ACSM. The Government of India has pledged to increase public investment in health care by an amount equivalent to 1–2% of GDP over five years. Other than India, funding needs according to the Global Plan amount to about US$ 650 million for low-income countries in 2007. This suggests that if 50% of needs in low-income countries were funded domestically, if middle-income countries financed their TB control entirely from domestic sources,2 and if donor resources were channelled primarily to low-income countries, then much of the increased funding required for implementation of the Global Plan could be mobilized from domestic sources.
While some countries need to mobilize additional funding, others face the task of maintaining their funding for TB control. Viet Nam, which has achieved the implementation targets of a 70% case detection rate and 85% successful treatment rate for several years, is the only one of the 22 HBCs where funding projected for 2007 is less than in 2002. This decrease in funding includes a reduction in government funding. Failure to maintain financial support for the NTP risks undermining TB control and could prevent implementation of the newer components of TB control included in the Stop TB Strategy.
Resource mobilization is more likely to be successful if it is based on a credible plan and related budget, if there is evidence that increased funding can be spent, and if there is proof that increased spending can be translated into improved TB control. For several of the countries with the largest numbers of TB cases, larger sums of money have been spent, and increased spending has been associated with an increase in the number of patients treated in DOTS programmes. Notable examples include Bangladesh, Brazil, China, India, Indonesia and the Russian Federation where, for a 100% increase in funding, there has been an increase in new smear-positive cases treated under DOTS of at least 61%. Similar figures also apply to five other HBCs with smaller absolute increases in treated cases: DR Congo, Kenya, Myanmar, Nigeria and the Philippines. In other HBCs, the relationship between increased spending and increased cases treated in DOTS programmes was much weaker or could not be demonstrated due to lack or apparent underreporting of expenditure data. This includes Afghanistan and Pakistan, both of which reported large increases in the number of cases treated in DOTS programmes between 2003 and 2005 and large funding gaps for 2007, but for which expenditure data appear to have been underreported. With better expenditure data, it would be easier to make a case for increased funding for TB control in these countries. Overall, the data also illustrate that, when assessing the impact of increased funding for TB control on the burden of TB, as will be done by the GFATM during 2007 and 2008, it is advisable to look first at the relationship between expenditures and outcome indicators (such as the number of patients treated or the number of patients successfully treated), prior to linking funding with impact indicators such as prevalence or mortality rates. In countries where there is no clear relationship, an in-depth analysis of how the increased funding was used and how the lack of a relationship with outcome indicators can be explained is warranted.
Strengthening the financial monitoring system
The financial monitoring system itself has grown in strength between 2002 and 2007, yielding more data of higher quality year-on-year. Nonetheless, there is scope for improvement. Beyond the 90 countries included in our analyses, there were a further 66 countries that submitted incomplete financial data. In at least some of these, it is probably possible to provide a complete report. Better data are needed for Thailand, which reported only partial data because, in their decentralized system, financial data are not reported or aggregated at national level. The South African NTP illustrates how it might be possible to address this difficulty – in 2006, the NTP manager sent the WHO data collection form to each of the country’s nine provinces for the first time, allowing an aggregated report to be prepared. Budgets and funding for collaborative TB/HIV activities that are included in national AIDS programmes need to be better understood, for example via better linkages with resource tracking work undertaken by UNAIDS.
In summary, there has been major progress in the financing of TB control during the six-year period 2002–2007, with big increases in budgets, available funding and expenditures. However, large funding gaps remain, and the gaps reported by countries for 2006 and 2007 would be larger still if country plans and assessments of funding requirements were fully aligned with the Global Plan. The Global Plan needs to be translated into country-owned plans and budgets, which should then underpin intensified efforts to mobilize the necessary resources.
2 As indicated for health care as a whole in the report of the WHO Commission on Macroeconomics and Health. See: Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Organization, 2001, pp. 166–167.