Planning and Budgeting for TB control: Opportunities for Bank Operations

1. Planning and Budgeting for TB control: Opportunities for Bank Operations Katherine Floyd, Andrea Pantoja Stop TB Department World Health Organization World Bank Washington, 6 March 2008

2. Overview • Background • Epidemiological burden of TB and progress towards global targets for control • The Stop TB Strategy and the Global Plan to Stop TB • Planning/budgeting at country level vs. the Global Plan • The WHO tool for planning and budgeting for TB control at country level • What is it? Main features • Why use it? • Promotion and practical application to date • Opportunities for Bank operations, with particular attention to Africa

3. 1a. Epidemiological burden of TB and progress towards global targets for control

4. Epidemiological burden of TB: latest WHO estimates for 2006 • 9.2 million new (incident) cases • 0.7 million among HIV-positive people • 56% in Asia • 29% in Africa • 1.7 million deaths • 0.2 million among HIV-positive people • 14.4 million prevalent cases • 0.5 million cases of multidrug-resistant TB (MDR-TB)

5. Global targets for TB control • Impact targets (MDGs, Stop TB Partnership) • Halt and reverse incidence by 2015 (MDG 6) • Halve cases and deaths by 2015 vs. 1990 baseline • Outcome targets, DOTS (WHA*, Stop TB Partnership) • Detect ≥ 70% of new sputum smear-positive (SS+) cases • Successfully treat ≥85% of detected new SS+ cases * World Health Assembly

6. Cases in millions 10 8 400 6 4 350 2 Africa 0 1990 1994 1998 2002 2006 300 South-East Asia 250 WORLD Cases per 100,000 population 200 Western Pacific 150 Eastern Mediterranean 100 Europe 50 Americas 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 Incidence rates stable or falling slowly 9.2

7. Prevalence Mortality 350 35 300 30 250 25 200 20 Cases per 100,000 population Deaths per 100,000 population 150 15 100 10 50 5 0 0 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 TB prevalence and mortality Target = 148 Target = 14 Total deaths from TB in 2006 = 1.7 million Falling… but need to fall faster to reach targets

8. 80 70 2006 60 50 target Deaths (per 100 000/year) 40 30 20 10 0 EUR AFR EMR AMR WPR SEAR World Africa and Europe furthest from targets Africa Europe Similar pattern for prevalence

9. Case detection increasing but at slower rate than 2002–2005 80 Target 70% 70 60 61% in 2006 50 40 CDR, smear-positive cases (%) 30 All new sm+ 20 DOTS sm+ 10 0 1990 1994 1998 2002 2006 2010 2014 Global Plan: 65% in 2006 78% by 2010

10. Treatment success target almost reached (globally) 84.7 86 84 83 82 82 82 81 82 80 79 79 77 77 Percentage 78 74 70 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2.34 million 244,662 Europe: 70%, Africa: 76%, Americas: 78%

11. Four of the 22 high-burden countries now in "target zone" China Viet Nam Indonesia Philippines DR Congo Tanzania Ethiopia MZB Kenya Nigeria Uganda South Africa Sot Zimbabwe

12. 1b. The Stop TB Strategy and the Global Plan to Stop TB, 2006–2015

13. WHO-recommended Stop TB Strategy

14. The Global Plan to Stop TB, 2006–2015 Plan is based on Stop TB Strategy and sets out scale at which interventions should be implemented in each year 2006–2015 to achieve 2015 MDG and Stop TB Partnership targets, globally and for 7 regions

15. Funding requirements 2006–2015 in the Global Plan to Stop TB Total required US$56.1 billion Expected on current trends US$25.1 billion Gap to fill US$31 billion

16. The Global Plan – what does its success depend on? • Whether or not country plans are consistent with the regional-level plans included in the Global Plan • Whether or not all the funding required for country plans is mobilized • Whether or not all planned activities/interventions are actually implemented (and have expected impact)

17. 1c. Planning and budgeting at country level vs. the Global Plan

18. Comparisons with the Global Plan

19. Comparisons with the Global Plan

20. Planning and funding of TB control, 2007 $3500m Total $3.1 billion Based on 84 countries with 90% global TB cases General health services $3000m TB/HIV Total $2.3 billion $2500m Other Total $2.0 billion Operational research $2000m $1500m ACSM/CTBC MDR-TB $1000m PPM/PAL* $500m DOTS Country budgets Available funding Global Plan to Stop TB

21. Comparison of country reports with Global Plan in Africa, 2007

22. MDR/XDR-TB treatment in 2007 Behind Global MDR/XDR Response Plan targets in the 3 regions where most treatment is needed CR = Country report Based on 106 countries with estimated 84% of global MDR cases

23. 2. The WHO TB planning and budgeting tool

24. Why has a TB planning and budgeting tool been developed? • To assist planning and budgeting in general, and in particular country planning and budgeting in line with the Stop TB Strategy and the Global Plan • Called a "planning and budgeting" tool to highlight that: • Plans should include a budget, but sometimes do not • Budgets should be based on and in line with plan goals, objectives and planned activities

25. Development process

26. The tool: what is it? • Excel-based tool that provides a ready-made framework for planning and budgeting for all recommended components of TB control • Components defined according to the Stop TB Strategy and related Global Fund "Service Delivery Areas" required for TB grant applications • One worksheet for each major component of TB control, within which there is a ready-made list ("checklist") of inputs/activities to consider for each component of TB control and default values to help users, including default values from the Global Plan See: www.who.int/tb/dots/planning_budgeting_tool/en/index.html (includes tool and accompanying documentation)

27. The tool – what is it? Ready-made framework for planning/budgeting for each component of TB control Choosing country via menu system selects correct set of epi/ demographic/financial historical data, projections and default values incl. from the GP Guidance available within tool Menu-driven system Status Bar Summary tables and figures automatically produced Application options to enhance user-friendliness

28. Why use the tool? Main benefits • Plans and budgets for TB control set out comprehensively in one place, in standardized format • Solid foundation for resource mobilization from national/local governments, Global Fund and other donors • Automatically produces summary budget tables required for applications to Global Fund and entire tool is structured in line with Global Fund requirements • Provides framework for monitoring and evaluation of plan implementation as well as comparisons among and within countries • Automatically produces financial information requested on annual WHO TB data collection form

29. Promotion • Presentation of tool and how it can be used at Global Fund preparation workshops in all WHO regions • Training workshops for technical partners, NTP managers and WHO regional and country office staff • Highlighting its existence in presentations at international meetings whenever appropriate • Posted on the WHO Stop TB website

30. Practical application • Priority in 2007 given to training and practical use in Africa • Two five-day workshops with follow-up have covered 35 of 46 African countries including all 9 "high-burden" countries and 2 of the other very "high-incidence" countries (Malawi, Zambia) • 11 countries not covered: • Algeria, Cape Verde, Comoros, Equatorial Guinea, Guinea-Bissau, Mauritania, Mauritius, Rwanda, Sao Tome and Principe, Seychelles, Swaziland • Complete plans and budget in the tool for 8 high-burden countries and 2 of the highest-incidence countries: • DR Congo, Ethiopia, Gabon, Kenya, Malawi, Nigeria, South Africa, Tanzania, Zambia • In process for: • Mozambique (due end March 2008), Uganda, Cameroon and others although current status needs to be verified • Demand for regional workshops in 2008 in L. America, SE Asia

31. Examples: completed and in process… Nigeria Tanzania Tanzania adapted time period in line with strategic plan, and funding categories

32. Examples: completed and in process… Zambia Zambia Kenya Kenya Zambia adapted time period for purposes of Global Fund application and funding categories; funding gaps now closed after Global Fund Rd 7 proposal approved

33. 3. Opportunities for Bank Operations

34. Examples of where the Bank can play an important role • Contributing to finalization of budgets using the tool e.g. via deployment of consultants, follow-up during WB missions • E.g. Cameroon, Swaziland • Helping to promote use of the budget figures in health sector-wide planning/budgeting • E.g. Kenya, Mozambique, Zambia • Using the budget figures as an input to sector-side work using the Marginal Budgeting for Bottlenecks (MBB) tool • Keeping WHO up-to-date/informed about relevant opportunities to feed the TB budgeting work into health sector-wide planning/budgeting/financing discussions