The Stop Tuberculosis Partnership is one of our top-rated charities and the one I will personally be giving to this year.

Like most charities, the Stop Tuberculosis Partnership has an admirable goal. It uses donations to fund grants of tuberculosis drugs to governments, and also assists them with (and monitors their implementation of) the WHO-recommended tuberculosis control strategy. It’s an appealing activity because:

• Tuberculosis is an infectious disease that is frequently fatal, yet highly treatable.
• Standard tuberculosis control is estimated at $150-$750 per death averted (independent estimate including all costs – more on the organization providing this estimate).
• The authors of the Copenhagen Consensus disease paper rate tuberculosis control as the #1 priority for donors (pg 51).
• The more drug-resistant forms of tuberculosis may represent a major catastrophe risk, making it particularly important to avoid medical mismanagement and inappropriate use of anti-tuberculosis therapy. We haven’t looked into the “catastrophic risk” aspect of TB control much, but I see this as an added benefit that would come from supporting a good TB control organization.

As with most charities, the story doesn’t end there – there is a lot that can go wrong with tuberculosis control, and we came at the Stop Tuberculosis Partnership with a lot of questions. But unlike most charities, the Stop Tuberculosis Partnership has provided stellar answers that have increased our confidence in what it’s doing. A sample:

Do governments use the drugs for treatment, or sell/lose/misuse the drugs?

• In order to receive the drugs, governments must agree to provide a certain level of coverage, i.e., free treatment for patients, as well as adhering to multiple other conditions of the WHO-recommended tuberculosis control strategy.
• Stop TB then performs spot checks of medical facilities (audits at locations chosen by Stop TB, not by the governments) as well as examination of country-wide data (particularly treatment success rates) and data reporting systems.
• Treatment success rates are generally high.

The answer to the above question relies on audits. Does Stop TB carry out these audits consistently and produce substantive information on country compliance? We have positive though not fully conclusive indications.

• We have seen four audit reports – those of the highest-burden countries – and found them to be quite substantive and straightforward about strengths and weaknesses of the TB control programs.
• We believe that the audits are carried out consistently, as Stop TB’s annual reports from 2003-2005 summarized the outcomes of audit reports from all drug grant recipients. Stop TB has changed its reporting format, but has told us that it still does audit all grantees.
• We have seen specific instances of funding being cut off for noncompliance. (See Stop TB’s progress reports). It is very rare to see a charity publicly disclosing a shortcoming like this, and to be able to confirm that it was handled appropriately.
• Details at the “Does it work?” section of our Stop TB review.

But even if the governments are carrying out quality tuberculosis control programs, how much of Stop TB’s support is really resulting in more coverage – as opposed to simply substituting for funds the government would have spent anyway? We would guess that there is a degree of “fungibility,” but feel that Stop TB takes significant steps to maximize the impact of its funds.

• Pre-grant, it conducts detailed analysis of governments’ other sources of funding.

• Post-grant, it examines trends in the coverage of treatment before and after it became a funder. Though these trends do not have the rigor of a randomized controlled trial, we feel they provide reasonable evidence that Stop TB’s funding results in additional coverage.
• Details at the discussion of this issue in our review.

Does Stop TB, itself, have room for more funding?

• Stop TB has provided us with analysis of projected revenues and expenses, showing a significant gap (about $10 million a year over the next four years). We are not cleared to post this analysis publicly, but Stop TB will consider sharing it with interested donors who contact them.
• We have also tried to dig into the exact meaning of this “gap,” and have only been partially satisfied with the response.
  • Stop TB has cited specific examples of underfunded countries whose “buffer stock” has had to be cut (so that they have enough drugs to treat the projected number of patients, but little margin for error).
  • It has also stated to us that more funding would enable it to approve the treatment of more patients.
  • It has not provided quantitative scenario analysis, so it’s hard for us to be fully concrete about what additional donations can be expected to lead to (in terms of # people approved for treatment and in terms of treating more people vs. providing “buffer stock”).
  • Details at the discussion of this issue in our review.

Bottom line

• Big picture: Stop TB is the best international example we’ve found of a “proven, cost-effective, scalable, transparent” charity. It focuses on one highly cost-effective and proven intervention, collects and shares the information needed to address the questions we’ve come up with (and then some), and projects a significant funding gap. It is both large (significant ability to absorb more funding) and programmatically focused. It has both an excellent goal/program (tuberculosis treatment) and outstanding reporting on how its specific activities are going.
• That doesn’t mean we have no concerns. There are a lot of moving pieces here and a lot of complexity (as with just about any charity working internationally). Stop TB takes all the measures we find reasonable to assess its impact, and provides a strong picture of impact overall, but we would guess that there are many problems that its audits simply aren’t comprehensive enough to catch, as well as questions about “fungibility of money” that can’t be fully answered.
• Tomorrow we will discuss VillageReach, a very different charity that we are ultimately slightly more confident in, although there are major pros and cons to both. I am personally giving to Stop TB because (a) I put more weight on preventing adult deaths than on preventing child deaths (and tuberculosis affects adults more than vaccine-preventable diseases do); (b) VillageReach works in the most remote areas, while Stop TB works in a great variety of areas. I prefer (all else equal) to help people in less remote areas, who I believe have more opportunities (for themselves and for helping others).