WHO report 2008
Global tuberculosis control
3.4 Comparisons with the Global Plan
The Global Plan sets out what needs to be done between 2006 and 2015 to achieve the MDG and related Stop TB Partnership targets for TB control (see also Chapters 1 and 2). To assess the extent to which planning and financing for TB control at country level are aligned with the Global Plan, the financial resources estimated to be required for TB control in the Global Plan can be compared with estimates that are based on the financial data reported by countries.
3.4.1 High-burden countries
For the 22 HBCs as a whole, expenditures (2006), planned costs and available funding for 2006–2008 according to country reports are compared with those derived from the Global Plan in Figure 3.12. In 2006, actual expenditures in HBCs were slightly lower than those estimated to be required in the Global Plan, particularly for collaborative TB/HIV activities and ACSM. Expenditures for DOTS and use of general health system resources for DOTS treatment were similar. These findings are in line with the progress in DOTS implementation, the shortfall in implementation of collaborative TB/HIV activities (e.g. HIV testing, CPT and ART for HIV-positive TB patients) and the need for guidance in implementation of ACSM discussed in Chapter 2.
In 2007 and 2008, planned costs based on country reports are higher than expenditures in 2006, mostly due to an increase in planned spending on DOTS implementation and MDR-TB treatment (almost entirely in the Russian Federation and South Africa). However, planned costs fall short of those estimated to be required in the Global Plan, with the gap widening between 2007 and 2008 from US$ 0.2 billion to US$ 0.5 billion. Moreover, the gap is bigger once the distortion caused by the high planned costs for MDR-TB treatment in just two countries is removed. If the “excess” costs for diagnosis and treatment of MDR-TB (compared with the Global Plan) in the Russian Federation and South Africa are excluded, then the gap between the financial resources estimated to be needed in country plans and the Global Plan reaches US$ 0.7 billion for the 22 HBCs in 2008. The shortfall in MDR-TB treatment applies in particular to China, India and Indonesia.
These aggregated comparisons conceal the fact that four HBCs have planned costs consistent with those detailed in the Global Plan in 2008: Afghanistan, Brazil, Kenya and the United Republic of Tanzania. In addition, there are four countries in which the discrepancy is due to the mid-2007 revision of the MDR-TB component of the Global Plan to include much more ambitious targets.1 With the exception of MDR-TB, country plans are consistent with the Global Plan in China, Myanmar, the Philippines and Viet Nam (see Annex 1).
As noted in Chapter 2, the Russian Federation and South Africa are unusual in having plans to treat more patients with MDR-TB in 2008 than the numbers anticipated by the Global MDR-TB and XDR-TB Response Plan. For collaborative TB/HIV activities, the shortfall is mainly in Cambodia, the Democratic Republic of the Congo, Ethiopia, India, Mozambique, Nigeria, Uganda and Zimbabwe. For ACSM, examples of countries with shortfalls include the Democratic Republic of the Congo, Ethiopia, India and Pakistan; exceptions with ACSM budgets comparable to or larger than those indicated in the Global Plan include Afghanistan, Brazil, Cambodia, Kenya and the Philippines. These country-by-country comparisons with the Global Plan are presented in Annex 1.
3.4.2 All countries
The financial data submitted to WHO allow total TB control costs for 2008 to be estimated for 86 of the 171 countries that were included in the Global Plan (22 HBCs and 64 other countries).2 These 86 countries account for 91% of all new TB cases arising each year.3 A regional comparison of costs and available funding based on (a) country reports and (b) the Global Plan is shown for these 86 countries in Figure 3.13.
Overall, country reports indicate planned costs of US$ 3.1 billion in 2008 (up from US$ 2.3 billion in 2007), compared with US$ 3.6 billion in the Global Plan. The main discrepancy evident from Figure 3.13 is the Global Plan’s higher estimate of the cost of collaborative TB/HIV activities, which the regional analysis shows is primarily due to differences with country reports in the African and (to a lesser extent) South-East Asia regions. As noted above, however, the apparent similarity between the Global Plan and country reports for MDR-TB when data are aggregated for all countries is misleading. As Figure 3.13 makes clear, costs for MDR-TB treatment based on country reports fall far short of Global Plan expectations in the South-East Asia and Western Pacific regions, by about US$ 350 million in 2008. Within these regions, as also illustrated in Chapter 2, the shortfall is primarily in China and India The funding gap reported by countries amounts to US$ 385 million in 2008, but the gap is US$ 0.9 billion if the available funding of US$ 2.7 billion is compared with the US$ 3.6 billion requirement included in the Global Plan. The total funding gap further increases to US$1.2 billion once the distortion caused by unusually high planned costs and funding for MDR-TB treatment in the Russian Federation and South Africa is removed.
3.4.3 Implications of differences between country reports and the Global Plan
The differences between the Global Plan and country reports highlighted above suggest that country planning, budgeting and financing is lagging behind the Global Plan for three major components of the Stop TB Strategy: collaborative TB/HIV activities, diagnosis and treatment of MDR-TB, and ACSM.
For collaborative TB/HIV activities, the difference between the Global Plan and country reports is exaggerated. The data presented in Chapter 2 and Annex 1 show that although implementation of collaborative TB/HIV activities lags behind the Global Plan (consistent with the data presented in Figure 3.12 and Figure 3.13), there are a few countries in which implementation in 2006 and plans for 2007–2008 are well aligned, as also noted in this chapter. Some of the shortfall in the budgets reported by countries is attributable to only partial inclusion of the costs of collaborative TB/HIV activities in NTP budgets. For example, budgeting for all TB/HIV activities in the United Republic of Tanzania led to estimates for 2008 that are almost the same as those in the Global Plan, in contrast to previous years when the TB/HIV budget reported by the NTP was much lower. In Kenya, implementation is in line with the Global Plan, but the NTP budget does not include the costs of activities funded by the national AIDS control programme or the cost of activities that are funded via NGOs. In India, the only TB/HIV-related costs included in the NTP budget are the costs of HIV testing for TB patients, which is a relatively inexpensive intervention; it is not known to what extent other activities are budgeted for and funded by the national AIDS control programme. More comprehensive assessments of the kind recently undertaken for the United Republic of Tanzania are needed to enable a more accurate assessment of the real gap between the Global Plan and country plans, and the associated funding requirements.
The shortfall in budgets for diagnosis and treatment of MDR-TB clearly mirror the shortfall in implementation and planning described in Chapter 2. The reporting of budgets for ACSM that are relatively small as well as different from those included in the Global Plan is consistent with the reality that ACSM represents new territory for most NTPs, and that it is a component of the Stop TB Strategy for which NTPs state that guidance is needed (see Chapter 2).
WHO has developed a planning and budgeting tool that is designed to help countries to align their plans and budgets with the expectations set out in the Global Plan, as well as to produce more accurate country-specific estimates of the financial resources that are required.4 While the development of the tool was primarily motivated by a recognized need to assist countries to plan and budget in line with the Global Plan and the Stop TB Strategy, it is also intended to help with planning and budgeting for TB control in general. In 2007, 35 countries in the African Region were introduced to the tool through workshops and country missions, and several have used it to complete the task of setting out plans and budgets for a five-year period, starting in either 2007 or 2008. The countries that are most advanced include the Democratic Republic of the Congo, Gabon, Kenya, Malawi, Nigeria, South Africa, the United Republic of Tanzania and Zambia; progress has also been made in Ethiopia, Mozambique and Uganda. Outside Africa, the tool has been used in Afghanistan, Brazil, Indonesia and Uzbekistan, and will be introduced in all countries in the South-East Asia Region in 2008.
Review of finalized plans and budgets will increasingly inform and improve our comparisons of funding requirements reported by countries and those included in the Global Plan (e.g. as has been possible for Kenya, South Africa and the United Republic of Tanzania this year). For the 2009 report, this will include actual revision of the Global Plan estimates where appropriate, using up-to-date and country-specific data.
1 The Global MDR-TB and XDR-TB response plan 2007-2008. Geneva, World Health Organization, 2007 (WHO/HTM/STB/2007.387).
2 Four of the 90 countries that reported complete data were not considered in the Global Plan cost estimates.
3 All of the 171 countries included in the Global Plan accounted for 98% of TB cases globally in 2004.