WHO report 2008
Global tuberculosis control
3.3 Total costs of TB control
3.3.1 High-burden countries, 2002–2008
NTP budgets include only part of the resources needed for TB control. In particular, they do not include the costs associated with general health-service staff and infrastructure, which are used when TB patients are hospitalized or make outpatient clinic visits for DOT and monitoring. For the 22 HBCs combined, the total cost of TB control is projected to be almost US$ 2.3 billion in 2008, compared with US$ 0.6 billion in 2002 (Figures 3.7, 3.8 and 3.9; Table 3.4). As with NTP budgets, the total cost of TB control is expected to stagnate between 2007 and 2008, except in five countries (Brazil, Ethiopia, Mozambique, Nigeria and the United Republic of Tanzania).
Increases in projected costs during the period 2002–2008 arise because of the large increases in NTP budgets (described above) and, to a much lesser extent, because of the higher costs of clinic visits and hospitalization that are associated with treating more patients. As in previous years, the largest costs in 2008 are for the Russian Federation and South Africa, which together account for US$ 1.3 billion (59%) of the total of US$ 2.3 billion (Figure 3.9; Table 3.4). China (US$ 225 million), India (US$ 111 million), Brazil (US$ 95 million) and Nigeria (US$ 80 million) rank third to sixth. These six countries account for 82% of the total cost of TB control in the 22 HBCs in 2008. Of the remaining countries, 13 have costs of US$ 30 million or less in 2008, while three (Indonesia, Kenya, the United Republic of Tanzania) have costs in the range US$ 35 million to US$ 62 million (Table 3.4, column 2). The countries with by far the largest projected absolute increases in annual costs between 2002 and 2008 are the Russian Federation and South Africa, followed by China (Figure 3.9; Table 3.4).
In South Africa, there are two major reasons for the high cost of TB control anticipated in 2008. Firstly, the costs associated with general district hospital and specialized TB hospital infrastructure are relatively high, due to the number of beds (approximately 8000 across the country’s nine provinces) as well as a unit price per bed-day that is higher in South Africa than in most other HBCs (around US$ 40 per day in TB hospitals to over US$ 100 in general district hospitals, reflecting the higher unit costs associated with a middle-income country). Secondly, there is a large budget for the diagnosis and treatment of MDR-TB (see also Annex 2 and section 3.2 above). The largest components of the budget for MDR-TB in 2008 are renovation and construction of infrastructure in line with a new national policy of hospitalizing all patients with MDR-TB for at least six months, improvement of infection control in MDR-TB and XDR-TB units as well as in general district hospitals and provision of second-line anti-TB drugs for the enrolment of around 5000 patients on treatment.
High costs in the Russian Federation in 2008 reflect continued staffing and maintenance of an extensive network of TB hospitals and sanatoria, a large budget for second-line anti-TB drugs to treat many MDR-TB patients (US$ 267 million, with an estimated total of about 24 000 cases to be enrolled on treatment in 2008; see also Figure 3.3 and Chapter 2) and continued use of fluorography for mass population screening.
Funding for the general health-service staff and infrastructure used by TB patients during clinic visits and hospitalization is assumed to be provided by governments (see also Annex 2). This assumption, together with the implicit assumption that health systems have sufficient capacity to support the treatment of a growing numbers of patients in 2008,1 means that the resources available for TB control are estimated to have increased from US$ 0.6 billion in 2002 to US$ 2.0 billion in 2008 (Figure 3.8; Table 3.4). For all HBCs, the estimated gap between the funding already available and the total cost of TB control is US$ 328 million in 2008, i.e. the NTP budget gap reported above.
The contribution by HBC governments to the total cost of TB control in 2008 is 73% on average, which is slightly larger than their contribution to NTP budgets but very similar to figures reported for earlier years in previous reports in this series. Also as in previous years, this high average figure conceals important variation among countries (Figure 3.10). Seven HBCs are dependent on grants to cover around 50% or more of the total costs of TB control (Afghanistan, Bangladesh, the Democratic Republic of the Congo, Ethiopia, Indonesia, Kenya and Mozambique), and a further six (Cambodia, Myanmar, Pakistan, Uganda, the United Republic of Tanzania and Zimbabwe) that are likely to rely on grant funding to a similar or greater extent to fill reported funding gaps.
The share of the total costs provided by HBC governments is closely related to average income levels (Figure 3.11), although the government contribution relative to income levels is comparatively high in the Democratic Republic of the Congo, Ethiopia, India, South Africa, Viet Nam and Zimbabwe, and comparatively low in Cambodia, Indonesia, Kenya, Uganda and the United Republic of Tanzania.
3.3.2 All countries, 2008
Total costs for 86 countries that submitted complete financial data to WHO, which account for 91% of TB cases globally and which were also included in the Global Plan, are shown for 2008 in Figure 3.13.2 Overall, country reports indicate planned costs of US$ 3.1 billion in 2008, up from US$ 2.3 billion in 2007.
1 Nonetheless, the capacity of health systems to manage an increasing number of TB patients warrants further analysis, particularly in countries where the number of patients will need to increase substantially to achieve the MDG and related Stop TB Partnership targets for TB control.
2 Four of the 90 countries that reported complete data were not considered in the Global Plan cost estimates.