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Stop Tuberculosis Partnership

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Stop TB is a top-rated organization, receiving 3 / 3 possible stars (our highest rating). (What do our ratings mean?)

The Stop Tuberculosis Partnership aims to increase access to life-saving tuberculosis treatment using the World Health Organization's recommended approach ("DOTS") all across the developing world, primarily by providing government health programs with TB drugs through its Global Drug Facility.

The Partnership is a very large entity that we believe has a significant funding gap. We believe it is averting (adult) deaths from tuberculosis for under $1000 each.

Table of Contents

What do they do?

The Stop TB Partnership aims to increase access to "DOTS," the World Health Organization's recommended strategy for controlling tuberculosis. DOTS is a proven, cost-effective approach in reducing deaths and cases of TB. (For more information, see our full review of the DOTS program.)

The STOP TB Partnership's largest program is the Global Drug Facility (GDF). The chart below shows the Stop TB Partnership's expenses since 2003, separated into GDF and other areas.1

According to GDF Chief Operating Officer Robert Matiru, individual donations to the Stop TB Partnership support the Global Drug Facility.2 (We do not, however, see this claim confirmed on the donation page for Stop TB.3) Because both individual donations and Stop TB's funds are mostly allocated to the GDF, we focus our review on it.

The Global Drug Facility

The Global Drug Facility aids local governments or NGOs seeking to expand their DOTS programs4 by (a) granting TB drugs5 or (b) providing "direct procurement services" aiming to pool purchasers' funds and negotiate lower drug prices.6 In order to be eligible for GDF assistance, countries must be low-income, have a plan to expand TB programs, and agree to monitoring (both internal and external) of their TB programs.7

Since its creation in 2001, the GDF has primarily provided drugs through direct grants. The chart below shows the number of treatments provided by the GDF since inception by the means of provision.8

For the past 4 years, the GDF has provided treatments for approximately 2-2.5 million people annually.

Auditing recipients

The GDF audits all recipients of grants and services annually to ensure compliance with the recommended program.9 Six months after the drugs arrive, monitors (affiliated with Stop TB partners though not directly employed by Stop TB) assess the country's fulfillment of the agreed upon plan, program outcomes (cases detected and treatment success), and future drug needs.10 Monitors submit a report to GDF as well as external auditors.11

Other programs

The Stop TB Partnership Secretariat, the body that oversees Stop TB as a whole, also works on:12

  • Disseminating relevant information about TB and treatment programs.
  • Aiming to increase funding for TB control initiatives.
  • Coordinating among NGOs' and countries' TB control programs.

Does it work?

Medical treatment for tuberculosis is proven to work, and the "DOTS" strategy promoted by Stop TB has been associated with significant large-scale success stories of reduced mortality in the developing world. (For more, see our review of the "DOTS" strategy.)

The Stop TB Partnership, through the GDF, aims to increase the supply of drugs available for tuberculosis treatment, while requiring recipient governments to adhere to the "DOTS" strategy. From what we've seen of its auditing process and the results, we feel reasonably confident that (a) GDF recipients generally adhere to terms and conditions, run strong tuberculosis control programs, and stop receiving funding when they do not adhere to terms and conditions; (b) GDF drugs are generally used to expand tuberculosis control programs and treat most patients free of charge.

Recipients' adherence to terms and conditions

As detailed above, GDF conducts in-depth audits of drug recipients' TB control programs. Four of these reports were shared with us, though not cleared for public posting.13 These reports were not identical in form, and the amount of detail provided varied widely, but all included evidence that monitors completed unannounced visits to multiple facilities providing TB treatment and (a) interviewed providers and patients; (b) checked drug storage practices, expiration dates, and recordkeeping/reporting practices; and (c) checked the condition of facilities and equipment. They specifically reported that quality (unexpired) drugs were available, that drug allocation processes were set up to guard against misuses of drugs, and that treatments were being provided for free.

In addition, each report provides the "treatment success rate" for that country's program. "Treatment success" is defined as (a) those who were cured of TB plus (b) those who completed the treatment regimen, were not cured and did not die (i.e., they require additional treatment). In the four reports Stop TB sent us, the cure rate varied from 80%-91.3% and the "treatment success rate" varied from 84.6%-92.1%.

Are submitted reports representative?

Because of the fact that Stop TB chose which reports to share with us, it is possible that these represent the most positive or most thorough monitoring reports and are not representative of "normal" reports. However:

  • The GDF's Chief Operating Officer told us directly that these were picked because they are recent reports from high-burden countries (not because they are particularly positive).
  • The reports are not overwhelmingly positive; they report general compliance with terms and conditions but are also straightforward about concerns regarding quality control of non-GDF drugs, availability of appropriate equipment and expertise in certain areas, and monitoring and supervision among other things.
  • Stop TB's annual progress reports for 2003-2005 included aggregate results from these evaluations. These reports are publicly available. Most countries are reported to have been in compliance with GDF conditions, and those that were not appear to have stopped receiving funding.14 Reports from after 2005 no longer contain detailed country-level evaluations; a Stop TB representative told us that this change was made in order to make the reports more compatible with their readers (i.e., Stop TB's major funders).15
  • A 2008 overview of TB by the World Health Organization gives treatment success rates by country, worldwide.16 Of 22 countries listed, 15 have TB cure rates over 70% (note that of the remaining 7, 3 receive GDF support17).

Possible negative/offsetting impact: are GDF drugs "additional" or "fungible?"

It appears that GDF drugs are largely supplied to countries with working and effective tuberculosis control programs. However, a major question is whether drug grants are adding to the number of patients treated ("additional"), or simply substituting for drugs that would have come from other sources (in particular, from the recipient governments themselves).

GDF appears concerned with this question as well. Its country reports include the question "is there any evidence that GDF grant has displaced resources that would otherwise have been available from the government or other donors?" as well as detailed analysis of other projected sources of revenue from both the government and other donors (including the Global Fund). The reports we were sent conclude from this analysis that further GDF support is required to prevent stock-outs of drugs.

This analysis does not strongly address the possibility that governments are systematically relying on GDF for provision of drugs, and would otherwise provide these drugs themselves. To address this concern, GDF creates aggregate views of government spending before and after GDF support began.18 Data is not always available and the figures are not fully consistent, but in general, government expenditure appears to have risen rather than fallen with the onset of GDF support.

Other possible concerns about GDF's possible negative/offsetting impact include:

  • Diversion of skilled labor (more on this concern at our general discussion of negative/offsetting impact). Since all GDF grants are in the form of drugs (i.e., GDF does not provide additional funds to raise the monetary incentives for medical personnel), and since tuberculosis control appears to be one of the most effective and cost-effective medical interventions,19 we are not highly concerned about distorted incentives for medical professionals.

  • GDF recipients include governments such as Myanmar and North Korea. We questioned GDF representatives about this issue. They argued that because they are providing drugs (not money) and because of their strong auditing process, they feel confident that their support is resulting only in more patients being treated for tuberculosis.20

External evaluation

The Stop TB partnership has had a recent external evaluation (relatively rare among charities) performed by McKinsey.21 This evaluation included 8 country visits, a large number of interviews (and a survey) of people involved in tuberculosis control, and publication/data analysis.22 We do not find this evaluation to be highly specific on the details of the facts it collected and analyzed, but note that its overall conclusions are positive and that it provides country-by-country analysis of how TB control programs have changed and what the role of the Partnership has been in these changes.23

What do you get for your dollar?

The Disease Control Priorities report states that cost-effectiveness varies with local factors; the range estimated for a sustained program is $150-$750 per death averted and $5-$50 per disability-adjusted life-year (DALY) averted. More at our full review of the DOTS program; more on the DALY metric here.

Room for more funds?

The Stop TB Partnership has a public summary of the expected costs vs. revenues of the Global Plan to Stop TB,24 implying that TB control in general is substantially underfunded. However, the Global Plan to Stop TB involves many actors and funders other than the Partnership itself.25

The Chief Operating Officer of Stop TB's Global Drug Facility (GDF) listed several countries that cannot be fully provided with drugs given currently available amounts; GDF has not cleared us to disclose the specific countries, but has provided general comments on the situation.26

We also recently received analysis of GDF's expected revenue over the next 4 years and the resulting funding gap (although this analysis did not include a detailed breakdown of expenses), which we are not cleared to share publicly. In general, however, it appears that GDF has been successful in securing funding or pledges for most of its core activities from 2009 - 2012 but that a shortfall of approximately US $20 million exists for fully supplying TB medicines to eligible countries (see above paragraph) in 2009-2010, and a similar shortfall exists for both TB medicines and new planned initiatives in 2011-2012.

Financials/other

The charts below provide a summary of The Stop TB Partnership's finances. Data comes from publicly available documents.27 All data excludes donated drugs. Note that because Stop TB is not itself a US-registered charity (it takes donations through the UN Foundation), it does not provide its financials in fully standard form.

Revenue and expense growth (about this metric): Stop TB's revenues have risen in line with its expenses since 2003, with a large rise in revenues in 2007.

Assets-to-expenses ratio (about this metric): We do not currently have balance sheet data available for Stop TB.

Expenses by program area (about this metric): detailed above. The majority of Stop TB's funds are allocated to the GDF; in addition, donations from individuals are earmarked for GDF.

Expenses by IRS-reported category (about this metric): Because Stop TB is not an independent charity, it does not provide expenses by IRS-reported category. They do, however, report general, management, and administrative costs. Between 2003 and 2006, these ranged from $.9 to $2.7 million, approximately 2-4% of total expenses.28

Unanswered questions

  • Financials. We would like to see more financial data - particularly a balance sheet (from which we could take information about assets) and a detailed projection of expenses (which would inform our view of the "funding gap") - for the Stop TB Partnership.

Sources

  1. 1.

    Data for 2003-06 comes from the McKinsey External Evaluation of the Stop TB Partnership 2008: Data for the Global Drug Facility are on Pg 100; data for other expenses is on Pg 90.

    Data for 2007 comes from the Stop TB Partnership Annual Report 2007, Pgs 32-3. There is a slight discrepancy between total expenses for the Global Drug Facility as reported in Annex 1, on the Partnership's budget (expenses of $39.5m) and as reported in Annex II, on its budget (total expenses of $52.9m in 2007). This discrepancy is almost entirely explained by the line item for "Direct procurements" on the GDF budget ($12.5m in 2007). To arrive at the Partnership's total budget for 2007, we added $12.5m to the Partnership's total expenses.

  2. 2.

    Phone conversation with Robert Matiru, 6/17/09.

  3. 3.

    https://secure.globalproblems-globalsolutions.org/site/Donation2?idb=129..., accessed 6/30/2009.

  4. 4.

    "The GDF is an initiative to increase access to high quality tuberculosis (TB) drugs for DOTS implementation, a TB control strategy." http://www.stoptb.org/gdf/whatis/what_is.asp, accessed 6/29/09.

  5. 5.

    "All governments as well as non-governmental organizations (NGOs) working with the respective national health ministry are able to apply for a GDF grant. Countries complete an application including information on TB drug needs, a description of a DOTS expansion plan and the national TB programme, country statistics on TB and plans for distribution of drugs. Once approved (on the basis of application materials), a GDF team travels to the country to meet with government officials and evaluate drug needs and distribution capacity. Following the country visit, the application is either officially approved and terms and conditions of the grant finalized or the application is rejected." http://www.stoptb.org/gdf/whatis/what_is.asp, accessed 6/29/09.

    "The Global Drug Facility (GDF) grant service is a mechanism whereby first-line anti-TB drugs are granted to approved countries and non-governmental organizations (NGOs) to support DOTS expansion and sustainability of nationwide coverage in countries that are donor-dependent for their drug needs." http://www.stoptb.org/gdf/applying/application_documents.asp, accessed 6/29/09.

  6. 6.

    See Global TB Drug Facility Prospectus 2001, Pg 1.

  7. 7.

    Specifics:

    • "Annual per capita GNI under US$ 3000
    • National plan and budget for DOTS expansion to meet global targets
    • Technical guidelines demonstrating commitment to meet global targets
    • Annual report on DOTS performance (WHO TB collection form)
    • Recent external national TB programme review"

    From http://www.stoptb.org/gdf/applying/application_documents.asp, accessed 6/29/09.

  8. 8.

    Stop TB Partnership, Global Drug Facility: Progress Report 11 2007, Pg 5.

  9. 9.

    "Which programmes does the GDF monitor? All recipients of grants and DP services agree to, and receive, regular annual monitoring missions." http://www.stoptb.org/gdf/monitoring/faq.asp, accessed 6/29/09

  10. 10.

    Specifics:

    • "Adherence to GDF terms and conditions of support;
    • Programme management (including case detection and treatment outcome), financial management and drug management;
    • Estimated drug needs for the next year of GDF support; and
    • Follow-up on recommendations made by the Technical Review Committee (TRC) and by pre-delivery country visit and/or a previous monitoring visit."

    http://www.stoptb.org/gdf/monitoring/what_will_be_monitored.asp, accessed 6/29/09

  11. 11.

    "The monitoring mission submits a report to the GDF Secretariat, together with information on GDF drug arrival, customs clearance, drug registration, quarterly reports on case findings and treatment outcomes and annual WHO TB data collection form. This information, known as a monitoring dossier, is then sent to external auditors. The external auditor reviews the monitoring dossier for completeness, consistency and credibility. The auditor must also decide whether the information in the monitoring dossier is sufficient to enable the TRC to assess whether GDF terms and conditions of support as well as other monitoring requirements have been met. " http://www.stoptb.org/gdf/monitoring/what_will_be_monitored.asp, accessed 6/29/09

    The monitoring time line is available at http://www.stoptb.org/gdf/monitoring/monitoring_timeline.asp, accessed 6/29/09

  12. 12.

    See http://www.stoptb.org/stop_tb_initiative/secretariat.asp, accessed 6/29/09.

  13. 13.

    • Stop TB Partnership: Myanmar Monitoring Mission, 2008.
    • Stop TB Partnership: Bangladesh Monitoring Mission, 2008.
    • Stop TB Partnership: Tanzania Monitoring Mission, 2008.
    • Stop TB Partnership: Democratic People's Republic of Korea (North Korea) Monitoring Mission 2008.

  14. 14.

    Progress reports are available online at http://www.stoptb.org/gdf/whatis/documents.asp, accessed 6/29/09. For an example, see Progress Report 9 2005, Pg 36-44.

  15. 15.

    "At about that time we decided to shift to annual reports we decided to be a little more selective in what we report in a way that satisfies multiple donors' needs. Up to 2005 we were largely supported by CIDA. Since then USAID has become a big supporter and also the Netherlands and Norway. We didn't want the report to reflect the expectations of just one donor." Phone conversation with Stop TB representatives, 6/5/09.

  16. 16.

    World Health Organization 2008, pgs 29-30.

  17. 17.

    Progress Report 9 2005 gives the latest public summary of grant recipients; we do not yet have clearance to share the Drug Diagnostics Report, which is more up-to-date.

  18. 18.

    Progress Report 9 2005, Pgs 45-48.

  19. 19.

    See our overview of priority programs. Also note that a paper by the lead authors of the Disease Control Priorities report (accessed 6/30/09) lists tuberculosis control as the top opportunity for developing-world health aid.

  20. 20.

    Phone conversation with Stop TB representatives, 6/17/09.

  21. 21.

    McKinsey 2008.

  22. 22.

    McKinsey 2008, pg 75.

  23. 23.

    Discussions of specific countries begin on McKinsey 2008, pg 123.

  24. 24.

    http://stoptb.org/globalplan/funding_p1main.asp?p=1, accessed 6/30/09

  25. 25.

    Phone conversation with Stop TB representatives, 6/5/09.

  26. 26.

    "While funding provided to GDF by bi-lateral donors for Grants of TB medicines covers significant country gaps there have been instances where the overall funding requested by GDF was not provided by the donors. In these cases the required Grant covering the country's annual need for TB medicines, including an adequate security stock, had to be cut by approx. 25 - 50% (depending on the country). The key consequences of this are: (i) the countries are put at greater risk of stocking out of medicines and therefore interrupted treatment since the security buffer has to be reduced to sub-optimal levels or removed entirely from the Grant (ii) the countries have to reorganize internal stocks, which is a logistical and time/resource consuming challenge (iii) the countries have to seek supplementary support from other funding mechanisms often requiring time consuming application processes (iv) the countries may have to procure the difference themselves meaning they will likely buy higher priced products and/or products of uncertain quality and/or products with different packaging/presentation which is less cost-effective, riskier from a quality standpoint and complicates drug management and use for front-line health workers and patients respectively.” Email from Robert Matiru, 7/21/09.

  27. 27.

    Data for 2003-06 comes from McKinsey 2008. Data for the GDF is on Pg 100. Data for remainder of Stop TB is on Pg 90.

    Data for 2007 comes from the Annual Report 2007, Pgs 32-3. We made the same adjustment discussed in Footnote #1.

  28. 28.

    Data for 2003-2006 is in McKinsey 2008, Pgs 90 and 100. Data for 2007 is in the Annual Report (2007), Pg 32.

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