WHO report 2008
Global tuberculosis control
3.6 Expenditures compared with available funding and changes in cases treated
For countries that have received large increases in funding, there are two important challenges: to spend the extra money, and to translate extra spending into improved case detection and treatment success rates. To date, we have been able to conduct analyses for the HBCs only.
The ability to mobilize resources can be assessed by comparing available funding with budgets, and the ability to use financial resources can be assessed by comparing expenditures with available funding (Table 3.6; Figure 3.14). There were seven countries in which the NTP spent 80–100% of the funds available to them (Afghanistan, Brazil, Cambodia, China, the Democratic Republic of the Congo, the Philippines and Viet Nam) and three where expenditures exceeded the level of funding reported prospectively to WHO in 2006 (Kenya, Pakistan and South Africa).1 India spent 75% of the available funds, and Ethiopia spent 71%. The remaining six countries that reported expenditure data spent between 61% (Indonesia) and 69% (Myanmar) of the available funds. The data reported by the NTP in the United Republic of Tanzania indicate that only 24% of the available funding was spent; it seems likely that this is a problem with the expenditure report. No assessment could be made for Mozambique, Thailand and Uganda, as no expenditure data were reported; for these two African countries, as with the United Republic of Tanzania, reporting expenditure data to WHO has been a recurring problem. When country data are aggregated by region (Figure 3.14), the ability to mobilize and then spend financial resources in 2006 was best in the Region of the Americas, the European Region and the Western Pacific Region, and worst in the African Region (considering five countries that reported data, excluding South Africa where the magnitude of the budget and expenditures makes patterns in other countries hard to detect).
The ability to translate spending into improved case-finding can be assessed by comparing changes in expenditures 2003–2006 with changes in the number of patients treated 2003–2006 (Figure 3.15; 2006 is the most recent year for which both case notification and expenditure data are available). Of the 19 HBCs for which data were available, all of the 14 countries that increased spending between 2003 and 2006 also increased the number of new cases that were detected and treated in DOTS programmes (a similar pattern applied for new smear-positive cases specifically; data not shown). However, the relationship was variable. In Brazil and the Russian Federation, the increase in the number of patients treated under DOTS exceeded the increase in expenditures, probably because increasing the number of cases treated under DOTS requires a substitution of DOTS for non-DOTS treatment rather than an increase in total notifications. There was an almost one-to-one relationship between increased expenditures and increased notifications of new cases under DOTS in Indonesia, and the percentage increase in cases treated under DOTS was more than 70% of the percentage increase in expenditures in Bangladesh and China. At the other end of the spectrum, six countries reported lower expenditures in 2006 compared with 2003 (Afghanistan, Ethiopia, the Philippines, the United Republic of Tanzania, Viet Nam and Zimbabwe), of which two reported a small decrease in the number of cases treated (the United Republic of Tanzania and Zimbabwe), one reported a large increase in the number of cases treated (Afghanistan), and two reported small changes in the number of cases treated (the Philippines and Viet Nam). While the data are plausible for the Philippines and Viet Nam (small changes in both cases and expenditures are unsurprising in countries that have achieved targets for case detection and treatment success rates), it seems likely that expenditures have been underreported in the other four countries. This is consistent with the considerable difficulty in providing expenditure data to WHO that have been observed for these four countries over the past five years.
1 This explains why the value of expenditures in 2006 as a percentage of the available funding prospectively reported in 2006 (final column of Table 3.6) is above 100.