Paul NUNN - Stop TB

Expanding an accelerating access to tuberculosis diagnostics andlaboratory services

2nd meeting of the Global Laboratory Initiative, Veyrier-du-Lac

Scaling up management and control of multidrug resistant TB – what will it take?

Paul Nunn, WHO, Geneva

� Scaling up projections of the Global Plan to Stop TB, 2006-2015

Scaling up means to treat 80% of smear and/or culture-positive MDR-TB cases by 2015

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

2009 2010 2011 2012 2013 2014 2015

357,000

63,000

Target: Total patients treated over 7 years = 1.4 million

3x currently planned number

18x number planned for 2009

Global MDR and XDR –TB Response PlanIn 2009, 3% of incident cases treated according to WHO

standards

66

176

328

548

766

979

1,187

1,389

1,582

1 2 3 5 10 12 25 30 5083

139

231

385

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Th

ou

san

ds Response Plan (cumulative)

GLC approved (cumulative)

Expon. (GLC approved (cumulative))

What will it take?

� Money

� Greatly strengthened laboratories with new tools

� Infection control

� Coordination

� Global Plan projections of funding required for

MDR-TB, 2009–2015

S. Africa (55%)

Africa (other)

Russian

Federation

(30%)

Europe (other)

Asia

Budgets, 2009 (total US$ 438 million) Funding, 2009 (total US$ 72 million)

MDR-TB budgets and funding, 2009

Patients to be treated = 20,000

< 5% of estimated total of

435,000 cases

Estimated cases, 2007 (total 435,000)

Russian FederationAsia

Africa

Europe (other)

Source: WHO TB database

Cost per patient treatedN.B. "model of care" has major impact on treatment costs

Costs estimated from detailed costing studies in Tomsk (Russia), Estonia, the Philippines and Peru, adjusted for pattern of drug resistance, country income level, anticipated use of hospitalization

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Europe W Pacific SE Asia Africa

US

$ (

200

6 p

ric

es)

Other

TrainingLaboratory tests and X-rays

Programme/data managementDOT visits

HospitalizationDrugs

As does expected level of drug resistance and cost of drugs

Funding required, 2009–2015

Total US$16.9 billion over 7 years, average US$2.4 billion per yearMuch higher than existing budgets and funding

10x 2009 budget61x 2009 funding

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2009 2010 2011 2012 2013 2014 2015

US

$ b

illi

on

s

Infection control

Lab diagnosis, monitoring

Treatment

4.4

2.1

0.7

Treatment costs, 2009–2015

Programme management, 25%

Second-line drugs, 53%

Hospitalization, 22%

Reducing cost of second-line drugs and use of hospitalization would substantially lower funding requirements

Main cost components, 2009–2015

Personal protective controls, 2%

Treatment

Laboratory diagnosis and monitoring

Infection control0%

20%

40%

60%

80%

100%

2009 2010 2011 2012 2013 2014 2015

Recurrent Capital

Managerial activities, 18%

Administrative controls, 40%

Engineering + environmental controls, 40%

Programme management, 25%

Second-line drugs, 53%

Hospitalization, 22%

Funding required by region

Most of the funding required is in Europe (total US$8.9 billion), followed by Asia (US$7.1 billion, mostly in China and India)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2009 2010 2011 2012 2013 2014 2015

US

$ b

illi

on

s

Africa

Asia

Europe

4.4

2.1

0.7

Funding requirements in context

0.0

1.0

2.0

3.0

4.0

5.0

6.0

2009 2010 2011 2012 2013 2014 2015

US

$ b

illio

ns

All other components (DOTS,TB/HIV, ACSM, etc)

MDR-TB

4,5461,728n/a

Hospitalised,Hospitalised

DRNon DR

4,2401,425n/aHospitalised, Community

DRNon DR

3,8981,088n/aCommunity, Community

DRNon DR

n/an/a1,045HospitalisedDR only

n/an/a758CommunityDR only

Scenario 3All Facilities

Scenario 2All TB Facilities and Community Health Centres

Scenario 1MDR Facilities

only

Predominant locus of care

DR or non DR

Infection control costs, 2009-2015 – 22 High Burden Countries plus 14 MDR HBCs

Work in progress as of October 2009

� How can the required funding be mobilized?

Can patients pay?

Catastrophic health expenditure defined as 40% of household "capacity to pay""Capacity to pay" based on income after basic subsistence needs are met

0%

500%

1000%

1500%

2000%

2500%

Estoni

aLa

tvia

Lith

uania

South

Afr

ica

Rus

sian

Fed

erat

ion

Kaz

akhs

tan

Bul

garia

Bel

arus

Chi

naA

rmen

iaIn

dones

iaPhi

lippi

nesA

zerb

aija

nU

krain

eG

eorg

iaIn

dia

Nig

eria

Pakis

tan

Rep

ublic

of M

oldov

aVie

t Nam

Ban

glad

esh

Uzb

ekis

tan

Kyr

gyzs

tan

Tajik

ista

nEth

iopi

aD

R Cong

o

Second-line drugs as % of average income (GNI) per capita

Treatment cost as % of average income (GNI) per capita

The Global Fund and UNITAID – the

good news

51 51

60

38 4037 39

50

62

0

200

400

600

800

1000

1200

1400

1600

1800

1 (16) 2 (28) 3 (20) 4 (19) 5 (24) 6 (35) 7 (21) 8 (29) 9 (33)

Round

US

$ m

illi

on

s

0

10

20

30

40

50

60

70

Ap

pro

va

l ra

te (

%)

Grant amount Phase 1 (2-year funding) Total budget approved (5-year funding)

Approval rate

0

100

200

300

400

500

600

700

800

DOTS TB/HIV MDR TB high

risk/IC

HSS/PAL PPM/ISTC Empower

people

OR

in m

illi

on

US

$

Round 6

Round 7

Round 8

Round 9

The Global Fund and UNITAID – the

sad news

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

2009 2010 2011 2012 2013 2014 2015

US

$ b

illio

ns

Total cost for MDR-TB (Global Plan)

Global Fund (all TB)

UNITAID (all TB)

0.7

2.1

4.4

0.32 0.04

NB. assumption

Global Fund

and UNITAID

financing

sustained at

2009 levels

Unlikely to finance more than a relatively small share of the costs of MDR-TB diagnosis and treatment, unless either

a) both agencies mobilize substantially more funding and/or

b) the cost of MDR-TB diagnosis and treatment can be reduced

Can HBC governments pay?

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2009 2010 2011 2012 2013 2014 2015

US

$ b

illio

ns

Upper-middle income

Lower-middle income

Low income

Belarus, Bulgaria, Estonia, Georgia, Kazakhstan, Latvia, Lithuania, Russian Federation, South Africa

Upper-middle income (GNI US$ 3706–11455)

Armenia, Azerbaijan, China, India, Indonesia, Philippines, Moldova, Ukraine

Lower-middle income (GNI US$ 936–3705 per capita)

Bangladesh, DR Congo, Ethiopia, Kyrgyzstan, Myanmar, Nigeria, Pakistan, Tajikistan, Uzbekistan, Viet Nam

Low Income (GNI <US$ 936 per capita)

Commission on

Macroeconomics and

Health (2001)

suggested middle-

income countries could

finance 96–100% of

health care needs

High Level Taskforce

(HLTF) on Innovative

International Financing

for Health Systems is

focusing on low-

income countries

� Some aspects of Coordination

The Green Light Committee

� Started up as a Committee – to give a green light to MDR management proposals – AND prevent development of further resistance

� GLC has approved 108 projects in 68* countries with 59,142 patients approved for treatment. About 20,000 have started treatment

� Also provides technical support for proposal development, follow-up, monitoring and evaluation and policy advice to WHO, and now to GFATM

� All GF MDR proposals require the "Green Light"

The Green Light Committee

� GLC ensures quality of drugs, using its own procurement agent buying from stringent drug regulatory agency approved suppliers, or WHO pre-qualified suppliers (Stream A)

� GLC will soon approve "Stream B" that allows countries to procure drugs themselves from similarly QA'ed suppliers

Some other things needing coordination

� Better information

� Involvement of the private sector

� Human resources� Training, planning, recruitment

� Technical support� Short-, middle-, long-term

� Centres of excellence

� Matching diagnoses with treatment

� Coordinating with other disease control programmes

Conclusions

� Substantial increases in funding are required for TB control going forward

� Fund-raising strategies need much more focus on national domestic expenditure needs

� More attention needed on reducing costs of commodities and models of care

� Countries may effectively postpone targets