WHO report 2008
Global tuberculosis control
3.2 NTP budgets, available funding and funding gaps
3.2.1 High-burden countries, 2002–2008
NTP budgets in 21 of the 22 HBCs have increased during the period 2002–2008, often by substantial amounts, but have stagnated in all but five countries (Brazil, Ethiopia, Mozambique, Nigeria and the United Republic of Tanzania) between 2007 and 2008 (Figure 3.1 and Figure 3.2; Table 3.3; Annex 1). There are insufficient data to make an assessment for Thailand. The total combined budget for the 22 HBCs in 2008 is US$ 1.8 billion, almost four times the US$ 509 million budgeted for in 2002, but just US$ 16 million higher than in 2007. The Russian Federation has by far the largest budget (US$ 722 million), followed by South Africa (US$ 352 million), China (US$ 225 million), India (US$ 67 million) and Brazil (US$ 64 million). These five countries account for 81% of the NTP budgets reported for 2008 by 21 HBCs. Three countries have budgets of around US$ 50 million (Indonesia, Nigeria and the United Republic of Tanzania), followed by Kenya with a budget of US$ 33 million. The remaining 13 HBCs have budgets of US$ 25 million or less in 2008.
In absolute terms, the budgetary increase in the Russian Federation far exceeds that in any other HBC, at US$ 560 million since 2002. The second largest increase is in South Africa (US$ 289 million), following comprehensive planning and budgeting for all components of the Stop TB Strategy during 2007, and likely more accurate budgeting for individual provinces than was possible in previous years. In both countries, large budgets for the diagnosis and treatment of MDR-TB are particularly striking (Figure 3.3). The Russian Federation and South Africa account for most of the amount that has been budgeted for MDR-TB across HBCs (US$ 506 million out of a total of US$543 million, equivalent to 93%).
In relative terms, the most striking budgetary increase is the 844% increase reported by the United Republic of Tanzania (Figure 3.4a; Table 3.3). This larger figure follows a planning and budgeting process that was completed in late 2007. The plan for 2008–2012 covers all elements of the Stop TB Strategy, is in line with Global Plan targets and includes a comprehensive assessment of the budget required for collaborative TB/HIV activities (both those funded and provided though the NTP and those funded and provided via the national AIDS control programme). This has brought the budget developed by the NTP to a level very comparable to that estimated in the Global Plan (see also section 3.4.1 below and Annex 1). If the budget for collaborative TB/HIV activities likely to be funded and managed by the national AIDS control programme is removed, the budget in the United Republic of Tanzania is approximately halved.
Other countries with large relative increases in their NTP budgets over the past seven years include Afghanistan, Brazil, Myanmar, Nigeria, Pakistan and South Africa. Countries with noticeably small increases in their budgets since 2002 are the Philippines and Viet Nam, reflecting the fact that both countries had already reached, or were close to achieving, the global targets for TB control in 2002.
DOTS accounted for easily the largest proportion of NTP budgets between 2002 and 2006, and in 2008 continues to account for much the largest share of the NTP budget in all of the 22 HBCs except the Russian Federation, South Africa and the United Republic of Tanzania (Figure 3.1; Table 3.3).1 In contrast to earlier years, a much larger proportion (around 30%) of total NTP budgets across all HBCs is accounted for by diagnosis and treatment of MDR-TB in 2007 and 2008, with the Russian Federation and South Africa accounting for just over US$ 500 million of the total of US$ 540 million. Collaborative TB/HIV activities remain a comparatively small component of NTP budgets for the HBCs as a whole, but account for more than 50% of the budget reported by the NTP in the United Republic of Tanzania and for a relatively large proportion of the budgets reported by several other African countries including the Democratic Republic of the Congo, Kenya, Mozambique, Uganda and Zimbabwe (see also section 3.4.1 and Annex 1). High costs for collaborative TB/HIV activities in the United Republic of Tanzania follow a comprehensive costing analysis, as noted above.
The large budget increases described above have been accompanied by big improvements in available funding (Figure 3.2, Figure 3.4b, Figure 3.5; Table 3.3). For all HBCs, funding for NTP budgets has increased by just over US$ 1 billion since 2002, reaching US$ 1.4 billion of the US$ 1.8 billion needed in 2008. Funding has also increased in all individual HBCs, although the increases range from less than US$ 5 million in six countries (Cambodia, Myanmar, the Philippines, Uganda, Viet Nam and Zimbabwe) to around US$ 100 million in China, around US$ 300 million in South Africa and around US$ 400 million in the Russian Federation. As with NTP budgets, however, funding has stagnated between 2007 and 2008.
The extra US$ 1 billion of funding for NTPs in HBCs in 2008 (compared with 2002) has come mostly from HBC governments (including loans). This extra domestic funding amounts to US$ 0.8 billion (Table 3.3, columns 10–13) in total, an overall statistic that conceals the fact that most of the additional domestic funding has come from four countries only: Brazil, China, the Russian Federation and South Africa (an extra US$ 799 million including loans in 2008, compared with 2002). In other HBCs, increases in funding have come primarily from the Global Fund in 12 HBCs, from a combination of the Global Fund and grant funding in Indonesia, Kenya, Mozambique, and Pakistan, and mainly from donors other than the Global Fund in Afghanistan and Myanmar. Funding from the Global Fund in 2008 amounts to US$ 200 million compared with zero in 2002, and all HBCs except Myanmar have Global Fund grants. In relative terms, the most impressive improvements in funding overall (from all sources) have occurred in Indonesia, Mozambique, Myanmar, South Africa and the United Republic of Tanzania (Figure 3.5).
Among all HBCs, national governments will provide US$ 1194 million (66%) of the funding required by NTPs in 2008 and US$ 297 million (16%) will be funded by donor agencies (Table 3.3). This leaves a reported funding gap of US$ 328 million (18%). In absolute terms, the largest funding gaps are those reported by Brazil, China, Nigeria and the Russian Federation (US$ 252 million, or 77% of the total reported gap). Proportionally, the largest gaps are in Afghanistan, Cambodia, Kenya, Myanmar, Nigeria, Pakistan, the Russian Federation and Uganda (with gaps representing 31–73% of the required budget). Only five HBCs reported no funding gap, or a negligible funding gap: Bangladesh, Ethiopia, India, Indonesia and South Africa.
3.2.2 All countries by region, 2008
Data for all countries (in addition to the 22 HBCs) began to be collected in 2003 and were reported for the first time in 2004. There is variation in the set of countries that report complete data each year, making presentation of needs for all countries over time difficult. For this reason, Figure 3.6 presents NTP budgets by source of funding for 2008 only. In 2008, 90 countries (22 HBCs and 68 other countries) submitted complete financial data. Globally, these countries account for 91% of TB cases (up from 90% in 2007); at regional level, they account for almost all TB cases in the African, Eastern Mediterranean, South-East Asia and Western Pacific regions (89–97% depending on the region), for 74% of the regional total in the Region of the Americas, and for 60% of the regional total in the European Region.
NTP budgets in 2008 in these 90 countries total US$ 2.4 billion, up from US$ 1.6 billion in 2007 for countries accounted for 91% of TB cases globally, with a funding gap of US$ 385 million (also higher than the US$ 307 million gap reported in 2007).
Budgetary funding gaps as a proportion of the total budget were similar for HBCs and non-HBCs in the Region of the Americas and the Eastern Mediterranean Region, and much lower or non-existent in non-HBCs in the European, South-East Asia and Western Pacific regions. It is only in the African Region that funding gaps represent a higher share of the budget required in non-HBCs. Overall, NTP budgets per TB case (estimated annual incidence) were higher for HBCs compared with non-HBCs in the African Region, the European Region and the Region of the Americas, and much lower for HBCs compared with non-HBCs in the Eastern Mediterranean, South-East Asia and Western Pacific regions.
1 See Annex 2 for a definition of the budgetary line items included in the category DOTS.