Can Funding for TB be sustainable and flexible

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Can Funding for TB be sustainable and flexible?
Dr. Jacques Baudouy, Director Health, Nutrition
and Population Human Development Network The
World Bank
May 2, 2005
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Budgets for DOTS expansion have increased
significantly
a) Data not available for South Africa. ( refers
to heading, ?Total NTP budgets by source of
funding, 21 high-burden countries, 2002?2005) b)
Estimates assume budget 2002 equal to expenditure
2002 (Ethiopia), budget 2003 (Afghanistan,
Bangladesh, Mozambique and Uganda) and
expenditure 2003 (Russian Federation and
Zimbabwe). ?Unknown applies to DR Congo and
Nigeria, as breakdown by funding source not
available. c) Estimates assume budget 2003 equal
to expenditures 2003 for Mozambique, Russian
Federation and Zimbabwe. d) Budget data for UR
Tanzania based on 2004 data.
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GFATM now a major financier
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Funding gaps reported by National TB Programs
(NTPs) relatively small
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Financial situation reported by NTPs in Africa
US millions
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Are the identified funding gaps too small?

• Increased marginal costs at high case detection
  levels (harder to reach populations)
• Under-funding of interventions targeting specific
  patient groups (TB/HIV, MDR-TB)
• Lack of infrastructure in remote geographical
  areas
• Insufficient absorptive capacity

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Insufficient absorptive capacity?
High Burden Countries in 2004
The circled columns indicate that several
countries appear to have insufficient capacity to
actually spend the additional funds that have
become available during recent year.
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Insufficient absorptive capacity?
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Using increased funds efficiently

• Strengthening managerial capacity of local staff
• Hiring additional staff
• Improving management training
• Providing sufficient technical assistance
• Ensuring inclusion of adequate budget lines for
  TA in funding agreements

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Relatively large funding gaps remainin African
countries
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Total WB financing for TB control
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Addressing the African TB Financing crisis

• Urgent attention to identified funding gaps
• TA for GFATM proposals
• Review of GFATM funding patterns
• Potential for more WB funding (MAPs, health
  systems, PRSCs)
• Health system issues (infrastructure, manpower
  shortage) need to be addressed in a broader
  framework
• Include TB in broad financial frameworks (MTEF,
  PRSP)
• Africa TB Financing Summit

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World Bank Financing Terms A Snapshot

• Not a profit-maximizing Bank
• IBRD loans - Cost of the Banks own borrowing
  plus a lending spread
• IDA credits - Concessional rates, long grace
  period payback over 40 years
• Blend countries - Combined IBRD IDA
• IDA grants No repayment

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World Bank Financing Instruments Examples with
relevance to TB control

• Specific investment loans, credits and grants
  for projects
• Programmatic Operations and SWAps, e.g., Ghana
• Budget support through Poverty Reduction Support
  Credits and Grants (PRSCs), e.g., Rwanda
• Adaptable Programs covering multiple countries to
  increase flexibility, e.g., MAP for HIV/AIDS
• TB/HIV funding available through MAP (pilot in
  Mozambique, Eritrea, Rwanda, Tanzania in 2005)

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Ensuring long-term sustainability of funding

• 'Special funding streams' such as GFATM funding
  have inherent risks for long-term sustainability
• Long-term financing could be improved through
  inclusion of TB control activities in general
  planning financing mechanisms
• Examples
• Medium-term expenditure frameworks (MTEF)
• Poverty reduction strategy papers (PRSP)

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Medium-term Expenditure Framework (MTEF)

• The METF consists of a top-down resource
  envelope, a bottom-up estimation of the current
  and medium-term costs of existing policy and,
  ultimately, the matching of these costs with
  available resources in the context of the annual
  budget process.
• Objective plan strategic shifts not feasible in
  a single year where budget usually committed.

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Objectives of MTEF

• Improved macroeconomic balance, fiscal
  discipline
• Better inter- and intra-sectoral resource
  allocation
• Greater budgetary predictability for line
  ministries
• More efficient use of public monies
• Greater political accountability
• Greater credibility of budgetary decision making

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Stages of MTEF
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PRSPs

• Country authored, result- oriented, comprehensive
  road maps, based on domestic and external
  partnerships.
• Framework for domestic policies and programs to
  reduce poverty and basis for all IMF and WB
  concessional lending.
• Prioritization is necessary to balance the
  constraints of national capacity and demands of
  stakeholders
• Is tuberculosis being appropriately prioritized?
• Could PRSPs be used to mainstream tuberculosis
  control?

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Poor attention to TB in previous PRSPs
But, what level of detail is relevant for PRSPs?
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Gaps in the responsiveness of PRSPs to TB control
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Making the case for inclusion of tuberculosis in
PRSPs and MTEFs

• TB and economic growth
• TB is primarily a disease of the poor
• TB morbidity reduces household income
• TB may result in a 4 per cent to 7 per cent loss
  in GDP due to the potential cost of lost
  productivity.
• TB and MDGs
• For MDGs related to poverty (Goal 1)and
  infectious diseases to be met (Goal 6), TB should
  be addressed, whether directly or bundled with
  other MDG related health problems.

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Ways to mainstream TB

• HIV/AIDS and TB
• HIV/AIDS section in most PRSPs
• TB/HIV activities can be easily included
• By including a concurrent discussion on the
  impact of TB, a coordinated action plan for
  HIV/AIDS and TB can be outlined.
• Systems Strengthening
• Strengthening of health systems prioritized in
  many PRSPs
• Example Ethiopia
• Planning to implement Health Extension Package to
  provide community based health care and increase
  health coverage from 52 to 65
• Challenge to integrate TB programs into this
  system scale-up

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Conclusions

• Key Messages
• Integrate TB financing into PRSPs MTEFs,
  particularly for commodities
• Use complementary T.A. for speed and impact
  during implementation
• Caution keep emphasis on outcomes
• For Consideration
• Africa TB Financing Summit