International Development CommitteeWritten evidence submitted by UK Coalition to Stop TB
Introduction and Background on Tuberculosis (TB) and the Global Fund
1. Two billion people are currently infected with TB. In 2010, TB killed 1.45 million people.i Drug-resistant TB is emerging that is more costly and difficult to treat. In 2010 there were an estimated 650,000 cases of multi-drug resistant TB (MDR-TB).ii
2. The Global Fund has played a pivotal role in detecting and treating 8.6 million cases of TB over the past 10 years.iii By mid-2011 almost 20,000 patients had enrolled on Global Fund-supported MDR-TB treatment—an increase of almost 20% over 2010.iv The Fund’s Strategyv for 2012–16 aims to put another 21 million people on TB treatment, and advances in TB diagnosis and prevention have the potential to shift the TB response to the next level.vi
3. With the cancellation of Global Fund round 11, potential gains in TB control will be lost. The WHO Stop TB Partnership estimates that over the next five years, 3.4 million people will go untreatedvii and 1.7 million people will lose their lives to TB.viii
The Current Funding Situation of the Global Fund and DFID’s Contribution to the Fund
4. While bilateral donor funding plays an important role in tackling malaria and HIV/AIDS,ix the Global Fund accounts for 84%x of donor funding for TB.xi
5. The Department for International Development (DFID) currently has no bilateral programming planned for TB, and states that the Global Fund is the principle mechanism that the UK uses to drive its response to TB and HIV.xii
6. The Global Fund has created a Transitional Funding Mechanism (TFM) to support countries with active programmes that will no longer be able to access the new funding planned in the cancelled Round 11. The TFM places counter-part financing conditions on domestic governments.xiii
7. Despite domestic financing accounting for 86% of total funding for TB, TB programmes remain under-resourced.xiv Further pressure on domestic budgets to increase TB money, along with tight TFM restrictions means that it is unlikely that basic TB programming needs will be met, let alone be scaled up, or new patients reached.
8. Ten countries will finish their existing Global Fund TB grants in 2012, eight countries in 2013 and 10 in 2014. The Stop TB Partnership has projected that as a result, TB funding will be US$ 1.7 billion less than anticipated over the next five years.xv
9. Despite the UK government making commitments to increase its contribution to the Global Fund,xvi such commitments are yet to be realised. Now that the TFM application process has closed, a clear assessment can be made regarding the actual funding gap.
10. The Fund is making concrete progress in its reform agenda guided by the new General Manager, Gabriel Jaramillo and the Board Chair, (UK representative) Simon Bland. The UK is in a unique position to steer this agenda, and lead international donors to ensure the Fund is fully resourced whilst further reforms are undertaken.
The Prospects for DFID Achieving its Development Objectives if Current Funding Shortfalls at the Fund are not Addressed
11. The multilateral aid review rated the Global Fund as “very good value for money”, signalling a shift from bilateral funding for TB and HIV to a reliance on organisations such as the Global Fund to deliver on commitments.
12. Of the countries that will run out of TB grants over the next three years, 10 are DFID priority countries.xvii In all of these countries, DFID pledges to put women and children at the centre of their efforts.
13. TB is the third leading cause of death among women of reproductive age (15–44).xviii 500,000 infants and children become infected with TB annually and 70,000 die.xix Across its grant portfolio, the Fund addresses the gender dynamics that fuel TB, HIV and malaria.xx With DFID bilateral programming currently neglecting strategies and indicators to address the impact of TB on women and children, it is through Global Fund programmes that the UK will see results.xxi
14. In DFID’s HIV/AIDS position paper,xxii they emphasise the needs of the most vulnerable populations. The Global Fund reaches populations most at risk,xxiii who are often neglected by domestic TB programmes. The Fund supports social care initiatives that governments do not have the capacity to finance, but that are critical to TB treatment success, such as nutritional and anti-stigma programmes and psychological support for MDR-TB patients.xxiv
15. Unless the current funding crisis is addressed, UK objectives towards improving the lives of the most at risk and vulnerable, including women and children, will not be achieved.
The Impact on People in Developing Countries from the Delay in Funding of New Grants
16. Approximately 157,286 patients in Africa are at risk of TB due to the funding crisis. In Tanzania where the Fund provides 39% of the TB budget, 45,637 TB patients are at risk of not receiving treatment. 68,000 people will go undiagnosed, 6,000 of these will be children. Tanzania’s TB grant runs out in November 2012 and although Tanzania is eligible for the TFM, they will not be able to scale up any services, or reach new patients.xxv
17. The crisis presents a particular threat to the European region where middle-income countries such as Romania face a reduction in funding due to eligibility criteria.xxvi Despite overall progressxxvii drug resistant TB is a major concern in the region, particularly amongst hard to reach populations.
18. The European Member States have endorsedxxviii a plan to scale up the response to MDR-TB, taking into account new diagnostics, patient-centred models of care and tailored services for specific population.xxix Restricted funding now threatens the implementation of this plan in some of the highest MDR-TB burden countries in the world.xxx
19. It is estimated that the funding crisis will leave 244,000 people without TB treatment over the next two years.xxxi The numbers of people affected will only continue to multiply the longer the funding crisis continues, and UK development objectives in TB and HIV will not be met.
20. The UK must lead the international community to an urgent replenishment of the Global Fund to avoid current gains in TB control being lost.
Recommendations to the UK Government
21. Use its leadership position at the Fund to ensure the G20 Summit in Mexico in June 2012 is maximised to mobilise sufficient resources to create a new funding opportunity in 2012 and 2013.
22. Set an example to the donor community by increasing their contribution to the Global Fund—making an additional commitment of £384 millionxxxii over the three years replenishment period 2011–13.
23. Work with European counterparts to ensure that the needs of marginalised and vulnerable communities in countries no longer eligible for Global Fund support are met.
References
i Global TB Control Report 2011. Geneva, World Health Organization.
ii Tuberculosis Global Fact sheet (2011/2012) World Health Organisation http://www.who.int/tb/publications/2011/factsheet_tb_2011.pdf—Accessed 26.4.12.
iii Global Fund press release World TB Day 2012
http://www.theglobalfund.org/en/mediacenter/pressreleases/2012–03–23_World_TB_Day_10_years_of_sustained_Global_Fund_support/—Accessed 26 March 2012.
iv Global Fund press release
http://www.theglobalfund.org/en/mediacenter/pressreleases/2011–09–14_Global_Fund_supports_efforts_to_control_multi-drug_resistant_Tuberculosis_in_WHO_European_region/—Accessed 26 March 2012.
v The Global Fund to Fight AIDS, Tuberculosis and Malaria (2012). URL: http://www.theglobalfund.org/en/about/strategy/>
vi Such as conclusive data on treatment as prevention, early initiation of ART, male circumcision, pre-exposure prophylaxis, microbicides, use of IPT and diagnosis tools such as Genexpert.
vii Source: Unpublished data from the Stop TB Partnership, March 2012.
viii Ibid—this does not take into account the loss of a possible Round 12 in 2013.
ix Such as through PEPFAR for HIV/AIDS and DFID bilateral support for malaria.
x Global Fund press release
http://www.theglobalfund.org/en/mediacenter/pressreleases/2012–03–23_World_TB_Day_10_years_of_sustained_Global_Fund_support/
xi Although TB funding has increased by 50% since 2006, to an expected US$ 0.6 billion in 2012, it still falls far short of funding for malaria (US$ 1.8 billion in 2009) and HIV (US$ 6.9 billion in 2010—Global TB Control Report 2011. Geneva, World Health Organization.
xii Towards Zero Infections, The UK’s position paper on HIV/AIDS The UK Department for International Development (2011).
xiii An increase in domestic budgets for health is certainly needed—many governments remain a long way from fulfilling their commitments towards 15% of money for health—http://www.who.int/pmnch/media/press_materials/pr/2011/health_financing_scorecard.pdf
xiv Global TB Control Report 2011. Geneva, World Health Organisation, p 44.
xv Source: Unpublished data from the Stop TB Partnership, March 2012.
xvi A PQ from Andrew Mitchell on the need for reforms before a commitment will be made
http://www.publications.parliament.uk/pa/cm201212/cmhansrd/cm120220/text/120220w0002.htm#120220w0002.htm_sbhd70
xvii Burundi, Cambodia, Dominican Republic, Malawi, Mozambique, Sierre Leone, Sri Lanka, Tajikistan, Tanzania, Zambia.
xviii http://www.action.org/site/get_educated/tuberculosis_an_unchecked_killer_of_women
xix The true global burden of TB in children is unknown because of the lack of child-friendly diagnostic tools and inadequate surveillance and reporting of childhood TB cases.
xx The Global Fund for AIDS, TB & Malaria Global Fund Gender and Equality Strategy.
xxi A recent PQ from Andrew Mitchell acknowledged that the Global Fund has an important impact on MDG’s 4, 5 & 6
http://www.publications.parliament.uk/pa/cm201212/cmhansrd/cm120326/text/120326w0002.htm#120326w0002.htm_sbhd62
xxii Towards Zero Infections, The UK’s position paper on HIV/AIDS The UK Department for International Development 2011.
xxiii Such as prisoners, drug users, sex workers and the homeless.
xxiv For example, in Romania the Global Fund supports psychological support and social vouchers for transport and food, for MDR-TB patients. Without this support many patients would be lost to treatment.
xxv Source: Unpublished data from the Stop TB Partnership, March 2012.
xxvi Romania has by far the highest prevalence rate of TB in the EU, at 158.4 per 100,000, approximately 10 times the rate in the UK. Due to the funding crisis, it is estimated that 1,000 MDR-TB cases in Romania will remain undiagnosed with 500 not treated.
xxvii Tuberculosis surveillance and monitoring in Europe 2012 European Centre for Disease Prevention and Control (ECDC).
xxviii A “Roadmap to prevent and combat drug-resistant tuberculosis—The Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-Resistant Tuberculosis in the WHO European Region 2011–15”.
xxix The Action Plan can be accessed here: http://www.euro.who.int/en/what-we-publish/abstracts/roadmap-to-prevent-and-combat-drug-resistant-tuberculosis
xxx The Global Fund has granted funding for MDR-TB activities in 12 of the 15 high-burden countries in the European region.
xxxi Source: Unpublished data from the Stop TB Partnership, March 2012—The true impact is likely to be much higher, given that this estimate does not take into account the risk of untreated patients infecting 10–15 more people every year.
xxxii This figure may vary across submissions due to exchange rate fluctuations. Fair share calculations were made in dollars, with the UK’s being $1.245 billion. In 2010 that equated to approximately £840 million. Today it is closer to £780 million. The fact remains that the UK must more than double its contribution for this replenishment period (2011–13) to reach its fair share—at least an additional £384 million.
May 2012