5.2 Costs faced by TB-affected households, social protection and human rights

The World Health Organization (WHO) End TB Strategy targets for reductions in tuberculosis (TB) disease burden (incidence and mortality) can only be achieved if everyone with TB is able to access diagnosis and treatment (1). This is not possible if costs (including direct medical expenditures, direct nonmedical expenditures and indirect costs such as income losses) are a major barrier to health care for people with TB. For this reason, both universal health coverage (UHC) and social protection are part of pillar 2 of the End TB Strategy, and one of the Strategy’s three high-level targets is that no TB-affected households face total costs that are catastrophic.

The political declaration at the second United Nations (UN) high-level meeting on TB, held in 2023, included a new target that all people with TB have access to a health and social benefits package by 2027 (2).

UHC means that everyone can obtain the health services they need without suffering financial hardship (3). Social protection is a set of policies and programmes designed to reduce and prevent poverty, vulnerability and social exclusion throughout the life cycle (4). These can help to address the social determinants of TB, improve treatment outcomes and mitigate the financial hardships faced by people with TB and their households.

In addition to the risk of financial hardship, people with TB can be exposed to conditions that increase their risk of poor health and social outcomes. Protection of human rights is essential to prevent and mitigate social exclusion and avoidable vulnerability, and to ensure optimal social and health outcomes.

Costs faced by people treated for TB and their households

In 2017, WHO established standard methods for conducting a national survey to assess the total costs incurred by people treated for TB and their households (5). Updated guidance was published in June 2025, based on experience from 35 national surveys conducted between 2015 and 2024 (6). Total costs faced by TB-affected households in these surveys are defined as the sum of direct medical expenditures, direct nonmedical expenditures and indirect costs (e.g. income losses); catastrophic total costs are defined as costs that exceed 20% of annual household income or expenditure. Since 2015, there has been substantial progress in survey implementation, particularly in the WHO African and Western Pacific regions (Fig. 5.2.1).

Fig. 5.2.1 National surveys of costs faced by people treated for TB and their households since 2015: progress and plans (as of August 2025)

By August 2025, 42 countries had completed a survey, including 21 of the 30 high TB burden countries; 13 surveys were completed in the period 2023–2024 (Fig. 5.2.2). Repeat surveys were completed in the Republic of Moldova and Viet Nam, and data collection for a repeat survey was underway in Brazil and the United Republic of Tanzania.

Fig. 5.2.2 Timeline of national surveys of costs faced by people treated for TB and their households that were completed 2015–2024 (as of August 2025)

In surveys completed between 2015 and August 2025, the average total cost per TB episode incurred by TB-affected households ranged from US$ 78 (95% confidence interval [CI]: US$ 62–97) in the Gambia to US$ 3800 (95% CI: US$ 3040–4560) in Mongolia (Fig. 5.2.3). The mean cost for all countries is shown in constant US$ prices for 2025 (i.e. costs have been adjusted for inflation since the year of the survey), to allow for fair comparisons.

Fig. 5.2.3 Average cost per TB episode^a incurred by TB-affected household (mean and 95% confidence intervals, constant 2025 US$), national surveys completed 2015–2025^b

The percentage of people treated for TB and their households that experienced catastrophic total costs (defined as >20% of annual household expenditure or income) ranged from 13% (95% CI: 10–17%) in El Salvador to 92% (95% CI: 86–97%) in the Solomon Islands (Fig. 5.2.4). The pooled average for all 40 countries that reported data to WHO, weighted for each country’s share of notified cases, was 47% (95% CI: 37–58%). Among 37 countries that reported disaggregated data, the percentage facing catastrophic total costs was much higher for people with drug-resistant TB, with a pooled average of 82% (95% CI: 71–93%).

Fig. 5.2.4 Estimates of the percentage of people treated for TB and their households facing catastrophic total costs (mean and confidence intervals),^a national surveys completed 2015–2025^b

The distribution of costs faced by people treated for TB and their households varied among countries (Fig. 5.2.5). However, it was evident that – despite the widespread norm of “free TB care” policies – TB-affected households still faced direct medical costs. Such costs accounted for a sizeable proportion (20% or more) of total costs in eight countries (the Central African Republic, the Congo, the Dominican Republic, Guatemala, Guinea, Kenya, Mali and Somalia). Minimizing direct medical costs borne by TB-affected households should be a high priority for national TB programmes (NTPs) and ministries of health.

The surveys also showed that actions are needed to eliminate direct nonmedical costs and to reduce indirect costs. The combined cost of transportation, food, accommodation, nutritional supplements and other nonmedical expenditures (“direct nonmedical costs”) accounted for a substantial share (50% or more) of total costs in 11 countries: the Central African Republic, Colombia, El Salvador, Fiji, Kenya, Mali, Namibia, the Solomon Islands, Timor-Leste, Uganda and the United Republic of Tanzania.

Indirect costs associated with lost income, loss of employment or time lost while seeking or staying in care accounted for the largest single share of total costs in 20 countries: Argentina, Bangladesh, Brazil, Burkina Faso, Cambodia, the Congo, the Gambia, Guatemala, Indonesia, Lesotho, Mongolia, Myanmar, Niger, Nigeria, Papua New Guinea, the Republic of Moldova, South Africa, Viet Nam, Zambia and Zimbabwe.

All cost categories are influenced by the model of TB care; for example, the extent to which there is reliance on hospitalization or outpatient care, the frequency with which attendance at health facilities is requested and the level to which services are decentralized to allow delivery of services as close as possible to where people live. They are also influenced by ease of access to the health facilities used to provide care, and the level of social protection.

Fig. 5.2.5 Distribution of costs faced by people treated for TB and their households in national surveys completed 2015–2025^a

In 2023, results from national surveys were used to produce model-based estimates of the percentage of people treated for TB and their households facing catastrophic total costs in all 135 low and middle-income countries (LMICs) (7). The model-based estimate for all countries was 55% (95% CI: 47–63%). Among the six WHO regions, the highest percentage was in the African Region: 68% (95% CI: 59–76%) (Fig. 5.2.6).

Fig. 5.2.6 Model-based estimates of the percentage of people treated for TB and their households facing catastrophic total costs in 135 low- and middle-income countries (LMICs), overall and by WHO region

Social protection

Social protection through a health and social benefits package is required to mitigate or eliminate costs faced by people with TB and their households and to improve adherence to treatment. At the second UN high-level meeting on TB in 2023, Member States adopted a new target that by 2027, 100% of people with TB should have access to a health and social benefits package (2).

Data about national policies related to financial and social protection for people with TB have been collected by WHO from 30 high TB burden countries since 2022 and from all countries since 2024.

Globally in 2025, the most common policies were free access to TB diagnosis and free access to TB treatment; these were reported by 163 and 166 countries, respectively (Fig. 5.2.7). Since 2022, there has been an increase in the number of high TB burden countries with policies for enablers to support adherence to treatment, cash transfers and measures to ensure food security. Measures to compensate for income loss are only available in 10 out of 30 high TB burden countries.

Fig. 5.2.7 National policies related to social protection for people with TB that were reported to have been in place in 2025, globally, by WHO region and for 30 high burden countries

The International Labour Organization (ILO) is the agency responsible for global monitoring of social protection and associated progress towards targets set in the UN Sustainable Development Goals (SDGs). Data collected by the ILO are for the general population only, and do not cover specific populations such as people with TB. Nonetheless, there are two indicators that provide good evidence about overall levels of social protection, including in high TB burden countries. The first is the percentage of the general population that is effectively covered by at least one social protection benefit (being used to track progress towards SDG target 1.3.1); the second is public expenditure on social protection as a percentage of gross domestic product (GDP).

There is considerable country variation in the percentage of the population covered by at least one social protection benefit (Fig. 5.2.8). Coverage is above 80% in most parts of the WHO European Region and in a few countries in the WHO Region of the Americas and Western Pacific Region. Coverage is lowest in the WHO African Region.

Fig. 5.2.8 Percentage of population covered by at least one social protection benefit, by country, latest available year^a

Among the 30 high TB burden countries, the percentage of the population covered by at least one social protection benefit varies from 3.1% in Uganda to 94% in Mongolia. In 19 of these countries, the percentage is below 50% (Fig. 5.2.9). Coverage is strongly related to income level, ranging from an average of 9.7% in low-income countries to 86% in high-income countries. The global average is 52%, an improvement from 43% in 2015, when the SDGs were adopted by all UN Member States.

Fig. 5.2.9 Percentage of the population covered by at least one social protection benefit, 30 high TB burden countries,^a four income groups and globally,^b latest available year^c

When country values for the percentage of people covered by at least one social protection benefit are weighted according to each country’s share of the global number of people newly diagnosed with TB and officially notified as a TB case in 2024, the global average is 44%. This weighted average provides a more “TB sensitive” global figure related to the coverage of social protection.

In July 2025, the need for intensified efforts to improve levels of social protection was recognized by UN Member States in the “Sevilla Commitment” (the outcome document of the Fourth International Conference on Financing for Development) (8). The commitment is to expand the fiscal space for social protection with a view to increasing coverage by at least 2 percentage points per year in countries where social protection is not yet universal. The ILO, the Global Partnership for Universal Social Protection (USP2030) along with several other international agencies and development banks have committed to providing technical and financial support to countries with plans to improve coverage according to this target.

Public expenditure on social protection as a percentage of GDP varies considerably among countries, ranging from less than 5% in most countries in the WHO Africa and South-East Asia regions to 15% or higher in 26 countries, which are mostly high-income countries in the WHO European Region and the WHO Region of the Americas (Fig. 5.2.10).

Fig. 5.2.10 Public expenditure on social protection (excluding health expenditure) as a percentage of gross domestic product (GDP), by country, latest available year^a

Among the 30 high TB burden countries, public expenditure on social protection as a percentage of GDP varies from 0% in the Central African Republic to 17% in Brazil. In 22 of these countries, the percentage is below 5% (Fig. 5.2.11).

Expenditure on social protection as a percentage of GDP is strongly related to income level, ranging from an average of 0.80% in low-income countries to 16% in high-income countries. The global average is 13%.

Fig. 5.2.11 Public expenditure on social protection (excluding health expenditure) as a percentage of gross domestic product (GDP), 30 high TB burden countries,^a by income group^b and globally, latest available year^c

Human rights: protection from stigma, discrimination and social exclusion

Stigma and associated discrimination and social exclusion are major contributors to the vulnerability of people affected by TB (9). They can significantly increase costs incurred by people with TB: for example, if people with TB are evicted from their homes, if they lose their jobs, or if they are excluded from social protection programmes based on their clinical status or because of welfare stigma (defined as “the negative socio-physiological consequences“ or “psychic costs“ of receiving welfare benefits and being thus perceived a burden for the society) (3,10). Thus, in addition to access to social protection programmes to protect people affected by TB from financial hardship, people with TB need to be protected from stigma, discrimination and social exclusion.

In 2024, WHO requested countries to report data about the status of national laws and regulations against stigma, discrimination and social exclusion due to TB. Since changes to laws and regulations are relatively infrequent, countries were not requested to report data in the 2025 round of global TB data collection. Results from data reported in 2024 are reproduced below (11).

In 2024, 133 countries reported having national laws and regulations against stigma, discrimination and social exclusion due to TB. These included laws and regulations providing protection from job loss, housing eviction, parental rights in relation to children, access to congregate settings and compulsory isolation.

Protective policies were not yet in place in many countries in the WHO African Region, the Region of the Americas and the Western Pacific Region (Fig. 5.2.12).

Fig. 5.2.12 Status of national laws and regulations against stigma and discrimination due to TB, by country, 2024

(a) Protection from losing job

(b) Protection from housing eviction

(c) Protection for parental rights over children

(d) No restriction on access to congregate settings

(e) No compulsory isolation

For further information

Comprehensive documentation about the first national surveys of costs faced by people treated for TB and their households that were completed in 20 countries between 2015 and 2021, using WHO-recommended methods and for which results have been shared with WHO, is available in a book published by WHO in 2023 (12). This includes cross-cutting chapters on methods, results, policy implications and future direction, and profiles for each national survey in a standardized format. The coverage of social protection measures for people treated for TB and their households in these 20 countries is also summarized in Part II of the publication.

Further information on country experience in implementing these surveys between 2015 and 2024 as well as enhanced methodological developments and guidance is available in updated WHO guidance on surveys of costs faced by households affected by TB, published in June 2025 (6).

Further details about model-based estimates of the percentage of people treated for TB and their households facing catastrophic total costs in LMICs, including country specific details and results disaggregated by drug resistance status and household income quintile, are available in a journal article (7). The country-specific estimates for LMICs that have not yet implemented a national survey are also provided in the Global tuberculosis report app.

Further information about social protection is provided in guidance published in 2024 by WHO and the International Labour Organization (ILO) (4). The guidance aims to support the translation of existing best practices and current WHO and ILO policies into programmatic actions by NTPs, ministries of health and other relevant stakeholders. It sets out the essential concepts and operational steps needed to plan for and implement effective, sustainable and equitable social protection strategies to meet the socioeconomic needs of people affected by TB. Further details about social protection can be found in ILOSTAT and ILO World Social Protection for Climate Action and a Just Transition (13,14).

Further details about policies to protect people from stigma and discrimination can be found in the WHO global TB database.

References

1. The End TB Strategy. Geneva: World Health Organization; 2015 (https://iris.who.int/handle/10665/331326).

2. Resolution 78/5: Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis. New York: United Nations; 2023 (https://undocs.org/A/RES/78/5).

3. World Health Organization, International Bank for Reconstruction and Development & World Bank. (‎2023)‎. Tracking universal health coverage: 2023 global monitoring report. Geneva: World Health Organization; 2023 (https://iris.who.int/handle/10665/374059). License: CC BY-NC-SA 3.0 IGO.

4. World Health Organization & International Labour Organization. (2024). Guidance on social protection for people affected by tuberculosis. Geneva: World Health Organization; 2024 (https://iris.who.int/handle/10665/376542). License: CC BY-NC-SA 3.0 IGO.

5. Tuberculosis patient cost surveys: a handbook. Geneva: World Health Organization; 2017 (https://iris.who.int/handle/10665/259701). License: CC BY-NC-SA 3.0 IGO.

6. Consolidated guidance on tuberculosis data generation and use: Module 4: Surveys of costs faced by households affected by tuberculosis. Geneva: World Health Organization; 2025 (https://iris.who.int/handle/10665/381505). License: CC BY-NC-SA 3.0 IGO.

7. Portnoy A, Yamanaka T, Nguhiu P, Nishikiori N, Garcia Baena I, Floyd K, et al. Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysis. Lancet Glob Health. 2023;11:e1640-e7 (https://doi.org/10.1016/S2214-109X(23)00369-8).

8. Sevilla Commitment. Fourth International Conference on Financing for Development, Seville, Spain, 2025. United Nations Digital Library, New York: United Nations, 2025. (https://digitallibrary.un.org/record/4085602).

9. Tuberculosis among populations at high risk and people in vulnerable situations: policy brief. Geneva: World Health Organization; 2025 (https://iris.who.int/handle/10665/381848). License: CC BY-NC-SA 3.0 IGO.

10. Besley T, Coate S. Understanding welfare stigma: taxpayer resentment and statistical discrimination. Journal of Public Economics. 1992;48(2):165-183 (https://doi.org/10.1016/0047-2727(92)90025-B).

11. Global Tuberculosis Report 2024. Geneva: World Health Organization; 2024 (https://iris.who.int/handle/10665/379339). License: CC BY-NC-SA 3.0 IGO.

12. National surveys of costs faced by TB patients and their households, 2015–2021. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/366277). License: CC BY-NC-SA 3.0 IGO.

13. ILOSTAT. Geneva: International Labour Organization; 2025 (https://ilostat.ilo.org/).

14. World Social Protection for Climate Action and a Just Transition 2024–2026. Geneva: International Labour Organization; 2024 (https://www.social-protection.org/gimi/ShowWiki.action?id=52).

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