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

1. 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 2. 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 3. Opportunities for Bank operations, with particular attention to Africa Overview

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

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) Epidemiological burden of TB: latest WHO estimates for 2006

1.Impact targets (MDGs, Stop TB Partnership) Halt and reverse incidence by 2015 (MDG 6) Halve cases and deaths by 2015 vs baseline 2.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 Global targets for TB control

Cases per 100,000 population Africa South-East Asia WORLD Western Pacific Eastern Mediterranean Europe Americas Cases in millions Incidence rates stable or falling slowly 9.2

Mortality Deaths per 100,000 population Prevalence Cases per 100,000 population TB prevalence and mortality Falling… but need to fall faster to reach targets Total deaths from TB in 2006 = 1.7 million Target = 148Target = 14

AFR AMR EMR EUR SEAR WPR World Deaths (per /year) 2006 target Africa and Europe furthest from targets Africa Similar pattern for prevalence Europe

CDR, smear-positive cases (%) Target 70% All new sm+ DOTS sm+ 61% in 2006 Case detection increasing but at slower rate than 2002 – 2005 Global Plan: 65% in % by 2010

Treatment success target almost reached (globally) 244, million Europe: 70%, Africa: 76%, Americas: 78% Percentage

Four of the 22 high-burden countries now in "target zone" Zimbabwe China Viet Nam Philippines Indonesia Kenya DR Congo Uganda Nigeria EthiopiaMZB Tanzania SotSot South Africa

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

WHO-recommended Stop TB Strategy

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

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

The Global Plan – what does its success depend on? 1.Whether or not country plans are consistent with the regional-level plans included in the Global Plan 2.Whether or not all the funding required for country plans is mobilized 3.Whether or not all planned activities/interventions are actually implemented (and have expected impact)

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

Comparisons with the Global Plan

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

Comparison of country reports with Global Plan in Africa, 2007

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

2. The WHO TB planning and budgeting tool

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

Development process DateWork done April – May 2006Draft version of tool developed: Building on planning frameworks developed for Global Plan and STB workshops for Global Fund proposal development June – Dec 2006Field-testing + practical application: Malawi, Indonesia, Kenya, Somalia, South Africa, regional planning workshop for 10 priority countries in Latin America June – Dec 2006Revisions and finalization based on field-testing Oct – Dec 2006Accompanying documentation + sharepoint site prepared January 2007Translation into French, Spanish, Russian 2007 and early 2008 Two sets of major updates/revisions, most recent to facilitate Rd 8 Global Fund applications

The tool: what is it? 1.Excel-based tool that provides a ready-made framework for planning and budgeting for all recommended components of TB control 2.Components defined according to the Stop TB Strategy and related Global Fund "Service Delivery Areas" required for TB grant applications 3.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: ex.html (includes tool and accompanying documentation)

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

Why use the tool? Main benefits 1.Plans and budgets for TB control set out comprehensively in one place, in standardized format 2.Solid foundation for resource mobilization from national/local governments, Global Fund and other donors 3.Automatically produces summary budget tables required for applications to Global Fund and entire tool is structured in line with Global Fund requirements 5.Provides framework for monitoring and evaluation of plan implementation as well as comparisons among and within countries 6.Automatically produces financial information requested on annual WHO TB data collection form

Promotion 1.Presentation of tool and how it can be used at Global Fund preparation workshops in all WHO regions 2.Training workshops for technical partners, NTP managers and WHO regional and country office staff 3.Highlighting its existence in presentations at international meetings whenever appropriate 4.Posted on the WHO Stop TB website

Practical application 1.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 2.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 3.In process for: Mozambique (due end March 2008), Uganda, Cameroon and others although current status needs to be verified 4.Demand for regional workshops in 2008 in L. America, SE Asia

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

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

3. Opportunities for Bank Operations

Examples of where the Bank can play an important role 1.Contributing to finalization of budgets using the tool e.g. via deployment of consultants, follow-up during WB missions E.g. Cameroon, Swaziland 2.Helping to promote use of the budget figures in health sector-wide planning/budgeting E.g. Kenya, Mozambique, Zambia 3.Using the budget figures as an input to sector-side work using the Marginal Budgeting for Bottlenecks (MBB) tool 4.Keeping WHO up-to-date/informed about relevant opportunities to feed the TB budgeting work into health sector-wide planning/budgeting/financing discussions