Implementing the global plan to stop TB, 2011-2015--optimizing allocations and the Global Fund's contribution: a scenario projections study

Abstract

Background: The Global Plan to Stop TB estimates funding required in low- and middle-income countries to achieve TB control targets set by the Stop TB Partnership within the context of the Millennium Development Goals. We estimate the contribution and impact of Global Fund investments under various scenarios of allocations across interventions and regions.

Methodology/principal findings: Using Global Plan assumptions on expected cases and mortality, we estimate treatment costs and mortality impact for diagnosis and treatment for drug-sensitive and multidrug-resistant TB (MDR-TB), including antiretroviral treatment (ART) during DOTS for HIV-co-infected patients, for four country groups, overall and for the Global Fund investments. In 2015, China and India account for 24% of funding need, Eastern Europe and Central Asia (EECA) for 33%, sub-Saharan Africa (SSA) for 20%, and other low- and middle-income countries for 24%. Scale-up of MDR-TB treatment, especially in EECA, drives an increasing global TB funding need--an essential investment to contain the mortality burden associated with MDR-TB and future disease costs. Funding needs rise fastest in SSA, reflecting increasing coverage need of improved TB/HIV management, which saves most lives per dollar spent in the short term. The Global Fund is expected to finance 8-12% of Global Plan implementation costs annually. Lives saved through Global Fund TB support within the available funding envelope could increase 37% if allocations shifted from current regional demand patterns to a prioritized scale-up of improved TB/HIV treatment and secondly DOTS, both mainly in Africa--with EECA region, which has disproportionately high per-patient costs, funded from alternative resources.

Conclusions/significance: These findings, alongside country funding gaps, domestic funding and implementation capacity and equity considerations, should inform strategies and policies for international donors, national governments and disease control programs to implement a more optimal investment approach focusing on highest-impact populations and interventions.

Figure 1. Cases of drug-susceptible TB, MDR-TB and HIV-related TB that will be found according to the Global Plan to Stop TB (left); corresponding funding need (centre); and corresponding lives saved (right).

Notes to Figure 1: Global Plan forecasts based on date reported by NTPs to WHO up to 2009 , . Rows top to bottom: C&I: China and India; EE&CA: EECA; sub-Saharan Africa (SSA); L&MIC: Low- and middle-income countries not included in the other three regions. The cost of DOTS for drug-susceptible TB, MDR-TB and TB/HIV patients is included in ‘DOTS’ (blue circles & lines); yellow and pink bars cover the additional cost of providing MDR treatment or ART during DOTS treatment. Note that vertical axes do not start from zero.

Figure 2. Global Fund contribution to TB control, low- and middle-income countries.

(A): Expected Global Fund TB expenditures; (B): Corresponding proportional share in the total funding need for DOTS, MDR-TB and TB/HIV treatment. Note to Figure 2: Projections based on October 2010 donor pledges for 2011−2013.The projected decline after 2012 is larger for the Global Fund’s proportional contribution than for its absolute TB expenditures, as global TB funding needs continue to rise through 2015.

Figure 3. Global Fund TB allocations (top), corresponding cases treated (middle) and lives saved (bottom), across services (left) and regions (right), for three scenarios in 2015.

Notes to Figure 3: Scenario A assumes that regional allocations remain in the distribution of 2007–9 approved funding, with allocations among services following regional distributions of need according to the Global Plan to Stop TB. Scenario B maximizes mortality impact per dollar spent. Scenario C allocates money to DOTS+ART for TB/HIV patients and to MDR-TB treatment only. For comparison, left-most bars show results if grant distributions would exactly match total national funding needs as projected in the Global Plan. C&I: China and India; EE&CA: EECA; L&MIC: other low and middle-income countries; SSA: sub-Saharan Africa.