OPTIMISING INVESTMENT IN ROMANIA’S TUBERCULOSIS RESPONSE

TB resources, it is important to assess the best funding allocations across the different TB interventions. By considering both disease burden and defined objectives, an optimal allocation distributes budgets in the most efficient way across interventions, using evidence on intervention costs and effectiveness. The World Bank in collaboration with other partners has supported disease-specific allocative efficiency studies in more than 40 countries. TB allocative efficiency studies generally try to answer the question, “How can TB funding be optimally allocated to the combination of TB response interventions that will yield the highest impact?”


OPTIMISING INVESTMENT IN ROMANIA'S TUBERCULOSIS RESPONSE
This policy brief summarizes the findings of an allocative efficiency analysis and mathematical modeling effort using the Optima TB Model (http://optimamodel.com/tb), undertaken to support the Government of Romania in its national tuberculosis (TB) response. The full report can be accessed at (https://openknowledge.worldbank.org/handle/10986/32583) Under current conditions, Optima TB estimates that the incidence of TB will steadily fall from a rate of 82 per 100,000 in 2015 to 65 per 100,000 by 2035. Optima TB estimates that there were 6.3 million latent TB cases in Romania in 2015 and the delayed activation of so-called 'late-latent' infections remains a key driver for active-TB incidence. The prevalence of latent TB cases is increasing in the 65+ population, likely due to the aging of people who have lived through periods of very high TB incidence and may carry latent TB infections for many years. Latent TB prevalence is projected to stabilise around 2020 in this older population, and to be stable or to decrease slightly across all other populations until 2035.
Optimised allocations of TB expenditure are not projected to have a large impact on TB incidence. This is largely because TB incidence is primarily driven by people progressing to active TB from the large pool of latent-TB infections. As the national TB programme is focused on diagnosis and treatment of active TB, the interventions included in our analysis do not affect progression rates from latent-TB to active-TB. Reducing the incidence of TB will likely require broader strategies to address the social determinants of health, such as poverty levels, housing conditions and nutrition, which significantly impact progression to active TB.
KEY MESSAGE 2: By meeting national care cascade targets, Romania could reduce the total number of active TB cases by up to 17% by 2035. By meeting national targets for MDR-TB, Romania could achieve a 34% reduction in the total number of MDR-TB infections.
A scenario analysis was conducted to investigate the potential impact of reaching 2020 National Strategic Plan (NSP) targets on key TB indicators: • TB screening and diagnosis: The NSP aims to diagnose 85% of incident TB cases by 2020 • TB treatment initiation (linkage to care): The NSP aims for 100% of diagnosed cases to be linked to care • TB treatment outcomes: The NSP aims for overall treatment success rates of 90% of TB patients on treatment. Additionally, the NSP targets treatment success for 75% of MDR-TB cases.
The results from the scenario analyses of the total number of active-TB infections are shown in Figure 1ab below. Meeting and sustaining the aforementioned 2020 NSP care cascade targets is projected to yield reductions in the total number of active TB cases of up to 17% by 2035.
Similarly, meeting and sustaining the 2025 STOP-TB care cascade targets (diagnosis of 90% of new cases, treatment initiation of 100% of diagnosed cases, treatment success in 90% of treated cases) is projected to yield reductions in the total number of active TB cases of up to 12% by 2035 (detailed results available in full report).
The prevalence of latent TB cases is increasing in the 65+ population, likely due to the aging of people who have lived through periods of very high TB incidence and may carry latent TB infections for many years.

Figure 1ab Modelled impact on the total number of active-TB infections of meeting NSP care cascade targets (2015-35) a. Modelled number of people with DS-TB b. Modelled number of people with MDR-TB
Source: Optima TB model analysis for Romania.

KEY MESSAGE 3: An optimized allocation of resources could result in a 45% reduction in active TB cases and a 40% reduction in TB deaths by 2030.
This analysis estimated that TB expenditure in Romania amounted to approximately EUR 115 million in 2018, comprised mainly of health insurance contributions (49%) and state funding through the Ministry of Health (40%). The analysis then determined the mathematically optimal funding allocations for Romania's National TB Programme (Figure 2). The optimal allocation aims to simultaneously minimise the cumulative number of new active-TB infections, the total number of active-TB infections and TB-related mortality between 2018 and 2030. These were modelled as combined optimisation objectives. An optimal allocation of TB funding would increase funding for case finding programmes, reduce hospital-focused treatment and increase funding for DR-TB drug regimens containing new drugs. For detailed results, see Table 11 in the full report.
An optimal allocation of TB funding would increase funding for case finding programmes, reduce hospital-focused treatment and increase funding for DR-TB drug regimens containing new drugs.

Figure 2 Optimal allocation of current TB expenditure to simultaneously minimise cumulative TB incidence, prevalence and deaths between 2018 and 2035 in Romania
Source: Optima TB model analysis for Romania. Notes: 2018=base year (current allocation); Optimised budget: It was assumed that the budget of EUR 115 million that were available for TB-related programmes in 2018 would remain available on an annual basis up to 2035.

KEY MESSAGE 4: In order to make progress in Romania's TB response, it is imperative that current expenditure is maintained.
The analysis also explored the optimal investment pattern for different levels of spending (Figure 3ab). While the optimised allocation of current expenditure is projected to yield significant gains, there are diminishing marginal returns to spending over 100% of the budget. Reductions in TB spending to 80% of current levels, if optimally allocated, could result in a similar epidemic trajectory to those currently observed under baseline conditions in Romania. Reductions in TB spending to 60% of current levels would have a significant negative impact.
Given the context of TB financing in Romania, it is not guaranteed that any savings from reduced hospitalisation would be reallocated to other TB expenditure. An optimal allocation of current expenditure involves reduced hospitalisation for TB treatment, which reduces costs without affecting outcomes. These savings amount to approximately 20% of total expenditure. Therefore, an optimisation of 80% of current expenditure was conducted to see the effect on conclusions. Under this reduced budget, active case finding and second-line drugs for XDR TB are too expensive to be part of the optimal allocation. As such, to maintain or improve Romania's TB response, it is imperative that current expenditure is maintained and any savings from particular budget lines are reallocated to cost-effective TB diagnosis and care interventions where possible.
As such, to maintain or improve Romania's TB response, it is imperative that current expenditure is maintained and any savings from particular budget lines are reallocated to costeffective TB diagnosis and care interventions where possible.

Figure 3ab Modelled impact of optimised allocations on the number of active TB infections and TB-related deaths under different amounts of spending, Romania (2018-30) a. Active TB infections b. TB-related deaths
Source: Optima TB model analysis for Romania. Notes: 2018=base year (current allocation); Optimised budget: It was assumed that the budget available for TB-related programmes in 2018 would remain available on an annual basis up to 2035. Different expenditure amounts refer to proportions of the 2018 level of spending.
A significant positive health impact could be achieved by sustaining 2018 TB financing of EUR ~115 million and allocating that funding optimally. An optimal funding allocation includes:  This recognizes that those people whose TB remains undiagnosed are likely to be in vulnerable and hard-to-reach populations  In addition to allocative efficiency arguments, there is therefore also an equity argument for funding active case finding programmes, as it means that populations targeted by outreach activities would receive care that would otherwise not be available to them

Poverty reduction and late latency burden
 There are still approximately 6 million people in Romania with late latent TB infections. This is the main driver of active TB incidence  As the national TB programme is focused on diagnosis and treatment of active TB, the interventions included in our analysis do not affect progression rates from latent TB to active-TB  Reducing the incidence of TB will likely require broader strategies to address the This work is a product of the staff of The World Bank with external contributions. Note that The World Bank does not necessarily own each component of the content included in this work. The World Bank therefore does not warrant that the use of the content contained in the work will not infringe on the rights of third parties. The risk of claims resulting from such infringement rests solely with you.
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