Relation between disease-specific foreign aid for child health and burden of disease in sub-Saharan African countries

Background: Foreign aid for health has increased substantially in the past two decades. However, there is limited information on the relation between the distribution of foreign aid for health and the actual burden of disease in different diseases and age groups, particularly children. We examined the association between disease-specific foreign aid for children (FACH) and burden of disease. Methods: Burden of disease data including estimates of disability adjusted life years (DALYs) were derived from the WHO Global Health Estimates resource for 2000–11. Children 0–5 years of age in sub-Saharan African countries were examined and the number of DALYs lost for the top 15 diseases calculated. Data for foreign aid were derived from the AidData dataset, which includes descriptions of all foreign aid donations. We constructed an instrument that searched the text of each description for words indicative of a certain disease, such as “malaria” or “bed-net”, and designated child or infant in the age category. Findings: Overall, the amount of FACH increased substantially during the period 1996–2009, from US$3·5 billion in 1996 to US$13·5 billion in 2009. The relation between the burden of disease and the amount of disease-specific FACH was mixed. For example, diarrhoeal diseases were responsible for 19% of DALYs lost in 2009, and were targeted with 21% of FACH. By contrast, the amount of FACH targeted towards HIV in 2009 (5·5%) was much more than the that of lost DALYs caused by HIV (23%). Pneumonia, however, was responsible for the most DALYs lost in 2009 (29%) yet received only 0·6% of all FACH. Interpretation: Our findings suggest that the relation between the distribution of foreign aid for child health and burden of disease in sub-Saharan African countries is mixed. Further work is needed to analyse present distribution patterns of foreign aid for child health and to advise future distribution Funding: None

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models

Background: The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa. Methods: We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016–35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice. Findings: Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective. Interpretation: Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary. Funding: Bill & Melinda Gates Foundation

Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models

Background: The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements. Methods: 11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy. Findings: Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31–62%) and a 72% reduction in mortality (range 64–82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis. Interpretation: Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level. Funding: Bill and Melinda Gates Foundatio