Stop TB Partnership - July 2009 review

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 Stop TB Partnership has a strong monitoring process for determining whether drugs are used as intended. 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.

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, negotiate lower drug prices and provide quality assurance.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 2.25-2.75 million people annually.

Auditing recipients

The GDF states that it 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 to external auditors.11

Other programs

In addition to providing the first-line drugs for countries' DOTS programs, the GDF also provides:

• Direct procurement of diagnostic kits.12
• Grants and direct procurement of second-line drugs to treat multidrug-resistant TB.13
• Technical assistance.14

The graph below shows that second-line drugs comprise a small, but growing, part of the GDF's grant spending.15 The Stop TB Partnership Secretariat, the body that coordinates the work of the members of the Stop TB partnership, also works on:16

• Disseminating relevant information about TB and treatment programs.
• Increasing funding for TB control initiatives.
• Coordinating among partners and creating new partnerships.
• Funding a grant program to support innovation in TB case detection.17

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.18 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 record-keeping/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).19
• 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.
• The GDF annual progress report for 2005 includes aggregate results from these evaluations. Most countries are reported to have been at least partially in compliance with GDF conditions. Countries that were fully or partially in compliance received funding for the subsequent year. The one country that was not in compliance was not approved to receive funding for the next year.20 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).21
• A 2008 overview of TB by the World Health Organization gives treatment success and cure rates by country, worldwide.22 Of 22 countries listed, 15 have TB cure rates over 70% (note that of the remaining 7, 3 receive GDF support23).

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. For 2005 (the most recent year this data seems to be available), the GDF reported that government funding for TB had increased or remained the same after receiving support from the GDF in 12 countries and fell in 1 country. Data was not available for 9 countries.24 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,25 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.26 Data from 2005 shows government spending on TB in North Korea falling and then rising well over its original level after that country began receiving GDF support.27 We have not seen similar data for Myanmar.

External evaluation

The Stop TB partnership has had a recent external evaluation (relatively rare among charities) performed by McKinsey.28 This evaluation included 8 country visits, a large number of interviews (and a survey) of people involved in tuberculosis control, and publication/data analysis.29 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.30

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. What limited information we have on treatment success rates achieved by GDF-supported countries (see above) suggests that such rates are in line with the Disease Control Priorities report's estimates.31 More at our full review of the DOTS program and our discussion of the DALY metric. Between 2003 and 2008, Stop TB spent an average of about $24 per patient treatment provided (excluding direct procurements).32 Note that this figure is not the cost per patient treated, as it does not include many of the non-drug costs such as diagnostic equipment and health center costs.

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,33 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.34 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 resources; GDF has not cleared us to disclose the specific countries, but has provided general comments on the situation.35 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 information below provide a summary of The Stop TB Partnership's finances. Data comes from publicly available documents. All data excludes donated drugs and direct procurements. 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 2007.36 Assets-to-expenses ratio (about this metric): We do not currently have balance sheet data for Stop TB. Expenses by program area (about this metric): This is 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. It does, however, report expenditure on "general management and administration." Between 2003 and 2008, this ranged from 3.2%-8.5% of total expenses.37

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

• GiveWell. Guide to GiveWell's financial metrics
• GiveWell. Interpreting the DALY metric
• GiveWell. Tuberculosis case finding and treatment ("DOTS" approach)
• Jamison, Dean, Prabhat Jha, and David Bloom. 2008. Copenhagen Consensus 2008 challenge paper: Diseases (PDF).
• McKinsey and Company. 2008. Independent external evaluation of the Stop TB Partnership (2008) (PDF).
• Matiru, Robert. Stop TB Chief Operating Officer. Email on July 21, 2009.
• Matiru, Robert and other Stop TB representatives. Stop TB Chief Operating Officer and others. Phone conversation with GiveWell, June 5, 2009.
• Matiru, Robert and other Stop TB representatives. Stop TB Chief Operating Officer and others. Phone conversation with GiveWell, June 17, 2009.
• Stop TB Partnership. A new perspective on TB procurement. http://www.stoptb.org/gdf/whatis/newperspective.asp (accessed June 24, 2010). Archived by WebCite® at http://www.webcitation.org/5qjXK9vz2.
• Stop TB Partnership. About TB REACH. http://www.stoptb.org/global/awards/tbreach/about.asp (accessed June 24, 2010). Archived by WebCite® at http://www.webcitation.org/5qjXKQvCj.
• Stop TB Partnership. Annual reports:
  • 2004 (PDF).
  • 2005 (PDF).
  • 2006 (PDF).
  • 2007 (PDF).
  • 2008 (PDF).
• Stop TB Partnership. Drug diagnostics report. We have requested clearance to post this document publicly.
• Stop TB Partnership. GDF services. http://www.stoptb.org/gdf/applying/default.asp (accessed June 24, 2010). Archived by WebCite® at http://www.webcitation.org/5qjXKunLm.
• Stop TB Partnership. Filling the funding gap. http://stoptb.org/global/plan/funding/default.asp (accessed June 24, 2010). Archived by WebCite® at http://www.webcitation.org/5qjXL8xKO.
• Stop TB Partnership. Stop TB secretariat. http://www.stoptb.org/about/secretariat.asp (accessed June 24, 2010). Archived by WebCite® at http://www.webcitation.org/5qjXLOsV7.
• Stop TB Partnership. What is the GDF. http://www.stoptb.org/gdf/whatis/default.asp (accessed June 24, 2010). Archived by WebCite® at http://www.webcitation.org/5qjXLfV64.
• Stop TB Partnership. What will be monitored. http://www.stoptb.org/gdf/monitoring/what_will_be_monitored.asp (accessed June 24, 2010). Archived by WebCite® http://www.webcitation.org/5qjXLvUAN.
• Stop TB Partnership, Global Drug Facility. Achievements report (2007) (PDF).
• Stop TB Partnership, Global Drug Facility. Direct procurement service (PDF).
• Stop TB Partnership, Global Drug Facility. Monitoring mission: Bangladesh (2008). Stop TB has asked us not to publish this document online.
• Stop TB Partnership, Global Drug Facility. Monitoring mission: Democratic People's Republic of Korea (2008). Stop TB has asked us not to publish this document online.
• Stop TB Partnership, Global Drug Facility. Monitoring mission: Myanmar (2008). Stop TB has asked us not to publish this document online.
• Stop TB Partnership, Global Drug Facility. Monitoring mission: Tanzania (2008). Stop TB has asked us not to publish this document online.
• Stop TB Partnership, Global Drug Facility. Notes for Applicants (PDF).
• Stop TB Partnership, Global Drug Facility. Progress report 9 (2005) (PDF).
• Stop TB Partnership, Global Drug Facility. Progress report 11 (2007) (PDF).
• Stop TB Partnership, Global Drug Facility. Progress report 12 (2008) (PDF).
• Stop TB Partnership, Global Drug Facility. Progress report 13 (2009) (PDF).
• United Nations Foundation. Donate now: Stop TB Partnership. https://secure.globalproblems-globalsolutions.org/site/Donation2?idb=1297632662&df_id=3560&3560.donation=form1 (accessed June 24, 2010). Archived by WebCite® at http://www.webcitation.org/5qjXN56FB.
• World Health Organization. 2008. Global tuberculosis control (2008) (PDF). Geneva: World Health Organization.

• 1. Data from Stop TB Partnership, "Annual Reports (2004-2008)."
• 2. Robert Matiru and other Stop TB representatives, phone conversation with GiveWell, June 17, 2009.
• 3. United Nations Foundation, "Donate Now: Stop TB Partnership."
• 4. "The GDF is an initiative to increase access to high quality tuberculosis (TB) drugs for DOTS implementation, a TB control strategy." Stop TB Partnership, "What is the GDF."
• 5. "Both governments and non-governmental organizations (NGOs) in collaboration with the respective Ministry of Health are able to apply for GDF assistance. 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." Stop TB Partnership, "A New Perspective on TB Procurement." "The Global Drug Facility (GDF) grant service is a mechanism whereby adult and paediatric first-line anti-TB drugs are granted to approved countries and nongovernmental organizations (NGOs) to support DOTS expansion and sustainability of nationwide coverage in countries that don't have sufficient finances for their drug needs and who lack adequate procurement capacity, including a robust quality assurance system." Stop TB Partnership, "GDF Services."
• 6. "An exacting quality assurance policy ensures that all contracted suppliers have passed a rigorous quality assessment either through the WHO Prequalification Programme, through a stringent national regulatory authority (such as the US FDA) or through an Interim Review Process conducted by the WHO Prequalification Programme on behalf of GDF, the Global Fund and other partners financing or supplying essential medicines for TB, HIV and Malaria." "GDF's pooled procurement model and regular competitive processes for suppliers of anti-TB products allow GDF to negotiate low prices and then sustainably offer them to all its customers." Stop TB Partnership, Global TB Drug Facility, "Direct Procurement Service."
• 7. Specifics:
  • "Estimated GNI per capita equal to or less than US$ 3,000 per year. Highest priority will be given to countries with a GNP of less than US$1,000 per year."
  • "All drugs supplied by GDF will ONLY be used: a. for treatment of TB patients; b. free of charge to patients; c. in treatment regimens following WHO guidelines; d. in programmes following national guidelines for DOTS implementation; e. in accordance with a multi-year plan for DOTS expansion and sustainability to reach the global targets for TB control."
  • "Regular assessments of the NTP performance, including anti-TB drug management, will be carried out by an independent technical agency, and the complete assessment report provided to GDF. The applicant will also provide the following reports to the Stop TB Partnership secretariat: a. a regular annual report on TB programme performance in accordance with WHO guide- lines; b. quarterly reports on case finding, smear conversion and treatment outcomes; c. date of arrival of GDF drugs at port; d. time taken to register drugs (if applicable); and e. date drugs received in central drugs store."
  Stop TB Partnership, Global Drug Facility "Notes for applicants," Pg 2-3.
• 8. Data for 2001-2007 from Stop TB Partnership, Global Drug Facility, "Progress Report 11 (2007)," Pg 5, Graph 2.1. Data for 2008 and 2009 from Stop TB Partnership, Global Drug Facility, "Progress Report 13 (2007)," Pg 8.
• 9. "In principle, GDF support is given to countries for three years subject to availability of resources and satisfactory compliance with GDF conditions of support which include annual independent monitoring. All recipients of GDF grants for first-line tuberculosis drugs agree to regular assessment." Stop TB Partnership, "What Will Be Monitored."
• 10. "The areas on which assessment is based are:
  • Adherence to GDF terms and conditions of support;
  • Programme management (including case detection and
  • 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.
  Six months after GDF grant drugs have arrived in the country, a monitoring mission arrives composed of independent TB programme and drug management experts. The majority of these experts are affiliated with members of the STOP TB Partnership while some are independent consultants." Stop TB Partnership, "What Will Be Monitored."
• 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 GDF's external auditors, who are selected through a transparent competitive process. 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." Stop TB Partnership, "What Will Be Monitored."
• 12. "In 2007, GDF began providing diagnostic kits through its DP service to assist country programmes with the detection of TB." Stop TB Partnership, Global Drug Facility, "Progress Report 13 (2009)," Pg 16.
• 13. "Grants...Since project inception, fifteen (15) of the seventeen (17) approved countries have placed orders. In 2009, twelve (12) countries placed orders valuing US$4,203,670. Thirteen (13) countries received deliveries totaling US$ 5,688,264 in 2009...In 2009, 38 countries purchased anti”TB second line medicines through direct procurement, an increase compared to the 33 countries who procured through direct procurement in 2008. The value of medicines procured also increased from US$ 17,562,399 in 2008 to US $22,349,833 in 2009." Stop TB Partnership, Global Drug Facility, "Progress Report 13 (2009)," Pg 20.
• 14. "As part of its efforts to increase countries' capacity GDF provides technical support to National TB Programmes (NTPs), primarily via in”country missions...These missions are provided to countries using GDF's grant or direct procurement services, or to provide information and assistance to countries considering using GDF's services...In addition to the missions performed in country in 2009, GDF also performed six (6) workshops (Bangladesh, Belarus, Brazil, Pakistan, Tunisia and Uganda) focusing on drug management capacity building for first and second line medicines." Stop TB Partnership, Global Drug Facility, "Progress Report 13 (2009)," Pg 22-23.
• 15. Data from Stop TB Partnership, Global Drug Facility, "Progress Report 12 (2008)," Pg 12-17 and Stop TB Partnership, Global Drug Facility, "Progress Report 13 (2009)," Pg 32-34.
• 16. "The secretariat collects and collates information and resources produced by individual partners and disseminates them to the wider partnership...The secretariat, mainly through the ACSM Working Group, is involved in resource mobilization at three levels...Effective coordination is facilitated through structures and systems that evolve with the changing nature of the partnership...Mobilization of new partners includes identification of the comparative strengths of each partner, and development of structures to facilitate their contribution to the partnership." Stop TB Partnership, "Stop TB Secretariat."
• 17. "TB REACH will award grants between US $500,000 - US $1,000,000 annually to selected institutions or organizations that have put forward proposals in timely fashion, especially proposals that are innovative in detecting more TB cases." Stop TB Partnership, " About TB REACH."
• 18.
  • 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."
• 19. Robert Matiru and other Stop TB representatives, phone conversation with GiveWell, June 17, 2009.
• 20. Stop TB Partnership, "Progress Report 9 (2005)," Pg 36-44.
• 21. "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." Robert Matiru and other Stop TB representatives, phone conversation with GiveWell, June 5, 2009.
• 22. World Health Organization 2008, Pg 29, Table 1.5.
• 23. Stop TB Partnership, "Progress Report 9 (2005)," Pg 27-28 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.
• 24. Stop TB "Progress Report 9 (2005)," Pgs 36-44.
• 25. See our overview of priority programs. Also note that a paper by the lead editor of the Disease Control Priorities report (PDF) lists tuberculosis control as the top opportunity for developing-world health aid.
• 26. Robert Matiru and other Stop TB representatives, phone conversation with GiveWell, June 17, 2009.
• 27. Stop TB "Progress Report 9 (2005)," Pg 45.
• 28. McKinsey 2008.
• 29. "EVALUATION ACTIVITIES:
  • Conducted 94 interviews with people active at the global level in tuberculosis
  • Visited 8 countries – India, China, Indonesia, Burkina Faso, Uzbekistan, Peru, Kenya, Morocco
  • Conducted over 150 interviews in countries
  • Reviewed publications of Stop TB Partnership, WHO Stop Tuberculosis Department, and selected other documents
  • Analyzed available data on tuberculosis epidemiology, control metrics, funding, advocacy, and research & development
  • Conducted internet-based survey of 1,332 stakeholders with response rate as follows: Overall 17%, NTP managers 9%, Secretariat 61%, Coordinating Board 45%."
  McKinsey 2008, Pg 75.
• 30. For discussions of specific countries see McKinsey 2008, Pg 136-137.
• 31. "Many of the 182 national DOTS programs in existence by the end of 2003 have shown that they can achieve high cure rates: the average treatment success rate was 82 percent." Jamison, Jha and, Bloom 2008, Pg 294.
• 32. Spending data is from Stop TB Partnership, "Annual Reports (2004-2008)." Patient treatments data for 2001-2007 from Stop TB Partnership, Global Drug Facility, "Progress Report 11 (2007)," Pg 5, Graph 2.1. Data for 2008 and 2009 from Stop TB Partnership, Global Drug Facility, "Progress Report 13 (2007)," Pg 8.
• 33. Stop TB Partnership, "Filling the Funding Gap."
• 34. Robert Matiru and other Stop TB representatives, phone conversation with GiveWell, June 5, 2009.
• 35. "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.” Robert Matiru, email to GiveWell, July 21, 2009.
• 36. Stop TB Partnership, "Annual Reports (2004-2008)."
• 37. Stop TB Partnership, "Annual Reports (2004-2008)."