5. Financing for TB prevention, diagnostic and treatment services

Progress in reducing the burden of tuberculosis (TB) disease requires adequate funding sustained over many years. The World Health Organization (WHO) began annual monitoring of funding for TB prevention, diagnostic and treatment services, based on data reported by national TB programmes (NTPs) in annual rounds of global TB data collection, in 2002. Findings have been published in global TB reports and peer-reviewed publications (1–3). Recognizing that not all international donor funding for TB is captured in the data reported to WHO, each year WHO complements its analysis of data reported by NTPs with an assessment of international donor funding for TB using donor reports to the Organisation for Economic Cooperation and Development (see featured topic). Since 2005, funding for TB research has been monitored by the Treatment Action Group, with findings published in an annual report (4).

The Stop TB Partnership’s Global Plan to End TB, 2018–2022 (the Global Plan) estimated that US$ 9.2 billion was required for TB prevention, diagnostic and treatment services in 128 LMICs in 2018, rising to US$ 15.6 billion in 2021 and US$ 16.1 billion in 2022 (5) (Fig. 5.1). It was estimated that an additional US$ 2 billion per year was needed for TB research. At the first United Nations (UN) high-level meeting on TB in 2018, Member States committed to mobilizing at least US$ 13 billion per year for TB prevention, diagnostic and treatment services by 2022, and an additional US$ 2 billion per year for TB research in the 5-year period 2018–2022. A new Global Plan, for 2023–2030, estimates much higher funding needs, of US$ 15–32 billion per year in LMICs (6); this includes funding for implementation of a new TB vaccine after 2027.

Fig. 5.1 Estimates of funding required for TB prevention, diagnostic and treatment services in 128 low- and middle-income countries^a, in the Global Plan to End TB 2018–2022

Data about spending on TB prevention, diagnostic and treatment services by major category of expenditure and source of funding in the period 2010–2021 have been reported to WHO by 136 low- and middle-income countries (LMICs) (Fig. 5.2). These countries accounted for 98% of reported TB cases globally in 2021.

Fig. 5.2 The 136 low- and middle-income countries included in analyses of TB financing, 2010–2021

Spending on TB prevention, diagnostic and treatment services in LMICs falls far short of the globally estimated need and the UN global target, and has fallen since 2019. In 2021, the total was only US$ 5.4 billion (Fig. 5.3). This is less than half of the amounts estimated to be required in 2020 and 2021 in the current Global Plan (2018–2022) and the global target set at the UN high-level meeting on TB.

Fig. 5.3 Spending on TB prevention, diagnostic and treatment services in 136 low- and middle-income countries^a compared with the global target set at the UN high-level meeting on TB of at least US$ 13 billion per year, 2015–2021

Explanations for the decline in total spending on TB between 2019 and 2020–2021 include reductions in the global number of people reported as diagnosed with TB in 2020 and 2021, compared with 2019 (Section 1, Section 3); changes to models of service delivery (e.g. fewer visits to health facilities and more reliance on remote support during treatment); and reallocation of resources to the COVID-19 response. For example, estimated spending on outpatient and inpatient care for TB patients fell by about US$ 0.4 billion between 2019 and 2020, mostly due to the fall in the number of people diagnosed and officially notified with TB, but also to reductions in the number of outpatient visits required during treatment in some countries.

Longer-term trends in total spending by category of expenditure show an increase between 2010 and 2014, a decline up to 2016, limited growth up to 2019, a fall in 2020 and stabilization in 2021 (Fig. 5.4).

Fig. 5.4 Spending on TB prevention, diagnostic and treatment services in total and by category of expenditure, 2010–2021, 136 countries with 98% of reported TB cases in 2021

Since 2014, spending on the diagnosis and treatment of drug-susceptible TB has fallen slightly. Spending on treatment of multidrug and rifampicin-resistant TB (MDR/RR-TB) has increased steadily since 2010: this growth is largely explained by trends in the BRICS group of countries (Brazil, Russian Federation, India, China and South Africa) (Fig. 5.5).

Fig. 5.5 Spending on drug-susceptible TB and MDR/RR-TB, 2010–2021, three country groups

Spending by source of funding shows a relatively consistent pattern in terms of the amounts and relative contributions from domestic and international donor sources (Fig. 5.6). In 2021, 79% of the funding used for TB prevention, diagnostic and treatment services was from domestic sources, similar to previous years. Between 2019 and 2021 there was a decline in spending from domestic sources (US$ 0.66 billion) and a slight increase in spending sources from international donors (US$ 0.06 billion).

Fig. 5.6 Spending on TB prevention, diagnostic and treatment services by funding source, 2010–2021, 136 countries with 98% of reported TB cases in 2021

The main source of international donor funding for TB is the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund). Its share of the total amount of international donor funding reported by NTPs to WHO was 76% in 2021. A comprehensive analysis of international donor funding for TB, including additional funding that is not channeled through NTPs, is one of the featured topics this report. Key findings include that the United States Government (USG) is the largest contributor of funding to the Global Fund and also the largest bilateral donor for TB; overall, the USG contributes close to 50% of international donor funding for TB.

Aggregate figures for the shares of funding from domestic and international sources in LMICs are strongly influenced by the BRICS group of countries. In combination, BRICS accounted for US$ 2.7 billion (64%) of the total of US$ 4.3 billion in 2021 that was provided from domestic sources (Fig. 5.7). Overall, 93% of the spending in BRICS and all spending in Brazil, China and the Russian Federation in 2021 was from domestic sources of funding. In other LMICs, international donor funding remains crucial. For example, in 2021 such funding accounted for 50% of the funding available in the 26 high TB burden and two global TB watchlist countries (Cambodia and Zimbabwe) outside BRICS, and 42% of the funding available in low-income countries (LICs).

Fig. 5.7 Spending on TB prevention, diagnostic and treatment services from domestic sources and international donors, 2010–2021, 9 country groups

Bangladesh, Cambodia, China and Zambia are examples of high TB burden countries that have steadily increased domestic funding specifically allocated to NTPs (as opposed to funding allocated more generally for inpatient and outpatient care, including for people with TB) in recent years (Fig. 5.8). There was a considerable reduction in domestic spending in India between 2020 and 2021; one explanation for this was less need for spending on second-line anti-TB drugs in 2021, given stocks that still existed from 2020.

Fig. 5.8 Spending by national TB programmes on TB prevention, diagnostic and treatment services in the 30 high TB burden countries and 3 global TB watchlist countries disaggregated by source of funding, 2010–2021 ^a

In 2021, 75 of the 136 LMICs reported that funding was not sufficient for full implementation of their national strategic plans for TB. The total funding gaps reported amounted to US$ 1.6 billion (Fig. 5.9), with the largest gaps reported by Indonesia (US$ 340 million), Nigeria (US$ 256 million), the Philippines (US$ 164 million) and China (US$ 109 million). Of the 27 LICs, 20 reported funding gaps that amounted to US$ 201 million in 2021.

The funding gaps reported by countries are much smaller than the gap between the needs estimated in the Global Plan and the amount of funding available in 2021. For example, in LICs the gap between the needs estimated in the Global Plan and the amount of funding available in 2021 was US$ 1.4 billion (US$ 1.7 billion compared with US$ 0.3 billion), compared with reported funding gaps in LICs in 2021 that amounted to US$ 201 million. A likely explanation is that the targets included in national plans for TB are much less ambitious than those set out in the Global Plan.

Fig. 5.9 Gaps between the funding required for national strategic plans for TB and available funding as reported by national TB programmes, by income group and by WHO region, 2010–2021

The total reported gap in 2021 amounted to US$ 1.6 billion.

Increases in both domestic and international funding for TB are urgently required. Variation in the share of funding from domestic sources within a given income group suggests that there is scope to increase domestic funding in some high TB burden and global TB watchlist countries (Fig. 5.10). Allocations by the Global Fund and its major donor (the US government, which is also the leading bilateral donor for TB) are currently the dominant influences on international donor funding for TB (see also the featured topics section of this report).

Fig. 5.10 Sources of funding and funding gaps reported for the TB-specific budgets included in national strategic plans for TB in the 30 high TB burden countries and 3 global TB watchlist countries, 2021^a

The median cost per person treated for TB in 2021, from a provider perspective, was US$ 1024 for drug-susceptible TB (Fig. 5.11).

Fig. 5.11 Estimated cost per patient treated for drug-susceptible TB in 117 countries, 2021^a

The median cost per person treated for MDR/RR-TB, from a provider perspective, was US$ 3434 in 2021 (Fig. 5.12). These amounts include all of the provider costs associated with treatment.

Fig. 5.12 Estimated cost per patient treated for MDR/RR-TB in 101 countries, 2021^a

Estimates of the costs incurred by TB patients and their households during diagnosis and treatment are available from national surveys (Section 6.2).

Further details about funding for TB prevention, diagnostic and treatment services are available in the country profiles and the Global Tuberculosis Report mobile app. Methods for data collection and analysis are described in a technical appendix.

Data sources for Figs 5.3–5.12: Data reported by NTPs and estimates produced by the WHO Global TB Programme. The data sources, boundaries, accounting rules, and estimation methods used in this report are different from those of the System of Health Accounts 2011 (SHA2011). The TB expenditure data reported here are thus not comparable with the disease expenditure data, including for TB, that are reported in WHO's Global Health Expenditure Database.

References