WHO report 2008
Global tuberculosis control
3.8 Why do funding gaps for TB control persist?
The 22 HBCs have reported a combined funding gap of US$ 328 million for 2008, while the funding gap reported for 90 countries (the 22 HBCs plus 68 other countries) amounts to US$ 385 million. In the context of the Global Fund having issued seven calls for proposals since 2002 resulting in funding commitments of over US$ 10 billion for HIV, malaria and TB control programmes, it may seem surprising that funding gaps for TB control persist.
TB proposals submitted to the Global Fund must first be approved by its Technical Review Panel, and the number of proposals that can be approved for funding by the Board is limited by the total financial resources available. The US$ 2.4 billion committed thus far for TB control (see section 3.7) represents about one quarter of total commitments to date; if funds were split evenly among AIDS, TB and malaria, this would increase to US$ 3.3 billion. The Fund began to disburse funds in 2003, and current commitments extend to 2012; funds committed to date thus equate to approximately US$ 240 million per year, with a theoretical maximum of around US$ 330 million per year. This simple analysis demonstrates that even if TB control programmes were to increase their share of Global Fund commitments to 33%, the total reported funding gap of US$ 385 million would not be eliminated, although it could be reduced by about US$ 100 million. Excluding funding gaps in four middle-income countries with more domestic resources (Brazil, China, the Russian Federation and South Africa), the gaps reported by countries fall to about US$ 100 million among HBCs, and to about US$ 60 million in other countries. In this context, filling funding gaps via the Global Fund appears more feasible, but depends on (i) the submission of high-quality and sufficiently ambitious proposals including well-justified budgets, (ii) the criteria used by the Global Fund to define countries eligible to apply for funding and (iii) the criteria used to allocate funds among the three diseases. In round 7, there was a decrease in funding for TB control proposals, and a decrease in the proportion of proposals that were approved compared with the peak in round 6. The relative success of round 6 followed the organization of a series of proposal development workshops by the Stop TB Department in WHO; to maximize resource mobilization for TB control programmes in future rounds, this level of assistance with proposal preparation may be needed in future.
If gaps reported by countries are difficult to fill via the Global Fund, then closing the additional gap that will open up if all countries plan in line with the Global Plan via the Global Fund appears unrealistic. Filling funding gaps in the years up to the MDG target year of 2015 therefore depends on domestic resource mobilization and/or external resource mobilization from donors other than the Global Fund.
Increasing domestic financing for TB control would mean a major shift from trends during the period 2002–2008, when almost all of the increase in domestic funding among the 22 HBCs was accounted for by Brazil, China, the Russian Federation and South Africa. Two ways to assess the extent to which countries can mobilize more domestic funds are (i) to compare the percentage of funding currently being provided from domestic sources with a country’s national income (measured as GNI per capita) to see if there are differences between countries with similar income levels and (ii) to compare costs and funding gaps per capita with total government health expenditure per capita (Table 3.7). Comparing countries with similar income levels and a similar TB burden suggests that there is scope for increasing domestic funding in several countries including Indonesia (compared with the Philippines), Pakistan (compared with India) and Kenya (compared with Mozambique). Comparing costs and funding gaps per capita with government health expenditure suggests that the countries with the most capacity to fund TB control from domestic resources are Brazil and China, followed by India, the Philippines, Indonesia and the Russian Federation. The countries with the least capacity to increase funding from domestic sources include the African countries (except South Africa), Afghanistan, Cambodia and Myanmar.
Besides grant funding from the Global Fund, the President’s Emergency Plan for AIDS Relief is a major source of donor funding, at least for collaborative TB/HIV activities, for most of the African HBCs as well as Viet Nam. With billions of dollars available through this plan, it is important that collaborative TB/HIV activities and related aspects of TB control (e.g. laboratory strengthening) are supported as much as possible – for example, as in happening in Kenya. UNITAID1 is also a relatively new source of donor funding for TB diagnostics and anti-TB drugs.
Overall, the importance of increasing both donor and domestic funding for TB control is highlighted in a recent publication.2 This included an analysis of funding needs according to the Global Plan for least-developed, low-income, lower middle-income and upper middle-income countries separately. Combined with benchmarks for domestic contributions to funding for health care used by the Commission on Macroeconomics and Health,3 this analysis suggested that domestic funding could increase to about US$ 5 billion per year by 2010 and that donor funding would need to increase to about US$ 1 billion per year (compared with approximately US$ 300 million in 2008).
2 Floyd K, Pantoja A. Financial resources required for TB control to achieve global targets set for 2015. Bulletin of the World Health Organization, 2008 [in press].
3 Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Organization, 2001:166–167.