Financing TB Control (2002–2007)
Financial analysis was introduced into the annual WHO report on global TB control in 2002. The main developments in the 2007 report are that (a) financial data are presented according to the six components of the Stop TB Strategy and/or the (related) cost categories used in the Global Plan, and (b) there is more detailed analysis of how funding needs reported by countries compare with the funding needs set out in the Global Plan. The report has seven objectives:
- For each HBC, and for all HBCs combined, to present and assess total NTP budgets and expenditures for the period 2002–2007, with breakdowns by funding source and line item;
- For each HBC and for all HBCs combined, to present and assess the total cost of TB control to government health services1 for the period 2002–2007, with breakdowns by funding source and line item;
- For each HBC, to estimate and compare per patient costs, budgets and available funding for the period 2002–2007 and per patient expenditures for 2002–2005;
- For each HBC, to assess whether increased spending on TB control is resulting in an increase in the number of cases detected and treated in DOTS programmes;
- To assess the contribution of the GFATM to funding for TB control;
- For countries other than the HBCs, to quantify NTP budgets and total TB control costs in 2007, with breakdowns by funding source and line item;
- For the HBCs and other countries, to compare funding requirements reported by countries with the funding needs for 2006 and 2007 set out in the Global Plan.
We collected data from five main sources: NTPs, the WHO-CHOICE team,2 GFATM proposals and databases, previous WHO reports in this series, and epidemiological and financial analyses carried out for the Global Plan.3 In 2006, data were collected directly from countries using a two-page questionnaire included in the standard WHO data collection form. NTP managers were asked to complete three tables. The first two tables required a summary of the NTP budget for fiscal years 2006 and 2007, in US$, by line item and source of funding (including a column for funding gaps). The third table requested NTP expenditure data for 2005, by line item and source of funding. The form also requested information about infrastructure dedicated to TB control and the ways in which general health infrastructure is used for TB control (e.g. the number of dedicated TB beds available, the number of outpatient visits that patients need to make to a health facility during treatment and the average length of stay when patients are admitted to hospital). We also asked for an estimate of the number of patients who would be treated in 2006 and 2007, for (a) smear-positive and (b) smear-negative and extrapulmonary cases combined.
Line items for the budget tables were revised from those used in previous years, to bring reporting of financial data in line with the Stop TB Strategy and to allow for comparisons with the cost categories used in the Global Plan. A total of 10 line items were defined: first-line drugs; dedicated NTP staff; routine programme management and supervision activities; laboratory supplies and equipment; second-line drugs for MDR-TB; management of MDR-TB (budget excluding second-line drugs); collaborative TB/HIV activities; ACSM, and community-based care; operational research; and all other budget lines for TB (e.g. technical assistance). The relationship of these items to the Stop TB Strategy and the Global Plan and the categories used for presentation of financial analyses in this report are shown in Table 6.
Data entry and analysis
Data entry and analysis focused on the 22 HBCs. We created a standardized Microsoft Excel workbook, with one worksheet for each country. Additional worksheets were included for summary analyses and for the data required as inputs to the country-specific analyses (e.g. notification data, unit costs for bed-days and outpatient clinic visits). For each country worksheet, 10 tables and related figures were created:
- NTP budget line items in 2006 and 2007, according to the 10 categories used in the 2006 round of data collection;
- NTP budget by line item for each year 2002–2007. Line items were grouped to allow for comparisons with the Global Plan and the Stop TB Strategy. This grouping, both for the budget categories used in 2006 and those used in 2002–2005, is explained in Table 6. This was supplemented by an additional table for the NTP budget 2002–2005, according to the detailed line items used in 2002–2005;
- NTP budget by source of funding for each year 2002–2007, with the funding sources defined according to the 2006 data collection form, i.e. government (excluding loans), loans, GFATM, grants (excluding GFATM) and budget gap;
- NTP expenditures by source of funding for 2002–2005, with funding sources as defined for NTP budgets;
- NTP expenditures by line item for 2002–2005, with line items defined according to the budget categories used for reporting in the 2005 round of data collection, i.e. first-line drugs, second-line drugs, dedicated NTP staff, initiatives to increase case detection and cure rates, collaborative TB/HIV activities, buildings/equipment/vehicles, and other. These categories were retained for expenditure data to allow direct comparison with budget data reported for 2005;
- Total TB control costs by funding source for each year 2002–2007, with funding sources as defined for NTP budgets;
- Total TB control costs by line item for each year 2002–2007, with line items defined as NTP budget items, hospitalization and clinic visits;
- Per patient costs, NTP budget, available funding, expenditures and budget for first-line drugs;
- Comparison of total costs based on the country report, with total costs implied by the Global Plan;
- Comparison of NTP budget, available funding and expenditure for 2003–2005 by line item.4
Budget data for 2006 and 2007 were taken from the 2006 data collection form. Budget data for 2005 were taken from the 2005 data collection form. Budget data for 2002–2004 were taken from the 2005 annual report. Expenditure data for 2002, 2003, 2004 and 2005 were based on the 2003, 2004, 2005 and 2006 data collection forms, respectively. Total TB control costs were estimated by adding costs for hospitalization and outpatient clinic visits to either NTP expenditures (for 2002–2005) or NTP budgets (for 2006–2007). Expenditures were used in preference to budgets for 2002–2005 because they reflect actual costs, whereas budgets can be higher than actual expenditures (for example, when large budgetary funding gaps exist or when the NTP does not spend all the available funding). When expenditures are known for 2006 and 2007, they will be used instead of budget data to calculate, retrospectively, the total cost of TB control in these years. For some HBCs, expenditures were not available for 2002–2005. When this was the case, we generally estimated expenditures based on available funding, which was calculated as the total budget minus the funding gap. The exception was South Africa, which reported budget and expenditure data for the first time in 2006. In previous annual reports, costs in South Africa were based on costing studies undertaken in the mid to late 1990s. Given the availability of new information from the 2006 round of data collection, we revised previous cost estimates for 2002–2004 by assuming that per patient costs in these years would be as for 2006. Total costs were then estimated by multiplying total notifications in each year by the estimated cost per patient treated. This produces lower estimates of total costs for South Africa, and explains differences in the total costs figures previously reported for the 22 HBCs during the period 2002–2006.
The total cost of outpatient clinic visits was estimated in two steps. First, the unit cost (in US$)5 of a visit was multiplied by the average number of visits required per patient (estimated on the WHO data collection form), to give the cost per patient treated. This was done separately for (a) new smear-positive cases and (b) new smear-negative and extrapulmonary cases. Second, we multiplied the cost per patient treated by the number of patients notified (for 2002–2005) or the number of patients whom the NTP expects to treat (for 2006–2007). The total costs for the two categories of patient were then summed. The cost of hospitalization was generally calculated in the same way, replacing the unit cost of a clinic visit with the unit cost of a bed-day. The procedure differed for eight countries that have dedicated TB beds, and where the total cost of these beds is higher than when the total cost is estimated by multiplying bed-days per patient by the number of patients treated (this applied to Bangladesh, Brazil, Cambodia, India, Myanmar, the Russian Federation, UR Tanzania and Zimbabwe). We assumed that all clinic visits and hospitalization are funded by the government, because staff and facility infrastructure are the major inputs included in the unit cost estimates and these are typically not funded by donors.
Per patient costs, budgets, available funding and expenditures were calculated by dividing the relevant total by the number of cases notified (for 2002–2005) and the number of patients whom the NTP expects to treat (for 2006–2007). Since the total costs of TB control for 2002–2005 were based on expenditure data, it is possible for the total TB control cost per patient treated to be less than the NTP budget per patient treated when the funding gap is large or there is a significant budgetary under-spend. In addition, for 2002–2005, expenditures per patient were sometimes higher than the available funding per patient. This can occur when the NTP budget funding gap is reduced after the reporting of budget data to WHO (since available funding is estimated as the total budget minus the funding gap). To try to eliminate this problem, the data collection form has allowed countries to update budget data reported in the previous round of data collection since 2005 (for example in the 2005 round of data collection, countries were able to update 2005 budget data originally reported in 2004; in the 2006 round of data collection, countries were able to update 2006 budget data originally reported in 2005).
Costs based on country reports reflect actual country plans for TB control. To address the question of whether these costs are in line with the Global Plan, we converted the regional costs that appear in the Global Plan into estimates for individual countries. While these costs should be seen as approximations only, they can be used to identify important similarities and differences between country reports and the Global Plan. Differences may occur if the intervention coverage and rates of scale-up (e.g. number of TB patients to be treated or number of HIV-positive TB patients to be enrolled on ART) planned by countries in 2006 and 2007 are more or less ambitious than the projections included in the Global Plan, and/or if country-specific budget development is based on input prices that are more or less than the average regional prices used in the Global Plan. A further reason for discrepancies is that, while the Global Plan includes the full cost of collaborative TB/HIV activities, the budget for these activities that is reported by NTPs include only the budget managed by the NTP, and not the budget for such activities that is managed by the national AIDS programme. Table 7 summarizes the methods used to convert regional costs as they appear in the Global Plan into estimates for individual countries.
All budget and expenditure data are reported in nominal prices (i.e. not adjusted for inflation) rather than constant prices (i.e. all prices adjusted to a common year) for two reasons. First, this means that values given for individual countries in Global tuberculosis control reports for the years 2002–2006 do not have to be adjusted, which makes it easier for country staff to review the data for previous years. Second, the adjustment makes only a small difference to the numbers reported (about 11% to 2002 values for total costs and less for other years).
Once the data were entered, any queries were discussed with NTP staff and the appropriate WHO regional and country office, and a final set of charts was produced. Six of these charts appear in the profiles for each country at Annex 1: NTP budget by line item 2002–2007, with line items as defined in the first column of Table 6; NTP budget line items in 2007, according to the line items used in the 2006 round of data collection; NTP budget by funding source 2002–2007; total TB control costs by line item 2002–2007; per patient costs, budgets, available funding, expenditures and budget for first-line drugs 2002–2007; and costs according to country reports compared with costs implied by the Global Plan for 2006 and 2007.6 In some instances, the review process led to revisions to data included in previous annual reports. For this reason, figures sometimes differ from those published in the 2002–2006 reports.
To assess whether increased spending on TB control has resulted in an increase in the number of cases detected and treated in DOTS programmes, we compared the change in total NTP expenditures between 2003 and 2005 with the change between 2003 and 2005 in (a) the total number of TB cases treated in DOTS programmes and (b) the total number of new smear-positive cases treated in DOTS programmes. This was done for all HBCs for which the necessary data existed (not all countries have reported expenditure data for both years).
Finally, we compared the total costs of TB control with total government health expenditure.7 We also examined the association between GNI (gross national income) per capita in 2005 and government contributions to total NTP budgets and TB control costs. Data on GNI per capita were taken from World development indicators 2005.8
For countries other than the HBCs, we used the data provided on the 2006 data collection form to assess NTP budgets by region in 2007, and compared these data with the budgets reported by the HBCs. Only countries that submitted complete data of sufficient quality (e.g. data whose subtotals and totals were consistent by both line item and funding source) were used.
We also made estimates of the costs implied by the Global Plan for the 172 countries in the regions covered by the plan, as described above for the 22 HBCs. We then aggregated these values for each WHO region for the subset of countries that (a) provided a complete budget report to WHO and (b) were included in the Global Plan. The total number of countries meeting both criteria was 62. We then compared these aggregated values to costs according to country reports.
GFATM contribution to TB control
We evaluated GFATM funding for both HBCs and other countries, as announced after the first six rounds of funding. We assessed total approved funding at the end of 2006, disbursements to the end of 2006, the time taken between approval of a proposal and the signature of grant agreements, and the time taken between the signing of the grant agreement and the first disbursement of funds. We also assessed how the total value of grants awarded for TB control has evolved between rounds 1 and 6, and the approval rate. The approval rate was calculated as the number of proposals considered by the GFATM Technical Review Panel in each round, divided by the number of proposals approved in each round (including proposals approved after appeal). This approval rate was compared with applications for malaria and HIV/AIDS.
1 i.e. including costs not reflected in NTP budget data.
2 The WHO-CHOICE (CHOosing Interventions that are Cost-Effective) team conducts work on the costs and effects of a wide range of health interventions.
3 The Global Plan to Stop TB, 2006-2015: methods used to assess costs, funding and funding gaps. Geneva, Stop TB Partnership and World Health Organization, 2006 (WHO/HTM/STB/2006.38).
4 Expenditure data are available for a larger set of countries in 2003 compared with 2002. For this reason, comparisons are with 2003.
5 Average costs in the WHO-CHOICE database are reported in local currency units. These were converted into US$ using exchange rate data provided in the IMF International financial statistics yearbook. Washington, DC, International Monetary Fund, 2003.
6 A full set of charts and data is available upon request to email@example.com
7 See www.who.int/nha/country/en
8 Accessed in December 2006: devdata.worldbank.org/data-query