4.1 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 Co-operation and Development (see Section 4.2). Since 2005, funding for TB research has been monitored by the Treatment Action Group, with findings published in an annual report (4).
At the second United Nations (UN) high-level meeting on TB in September 2023, Member States committed to mobilizing at least US$ 22 billion per year for TB prevention, diagnostic and treatment services by 2027, and US$ 35 billion per year by 2030; a target of US$ 5 billion per year by 2027 was set for investment in TB research (5). These targets were based on estimates of resource needs set out in the latest Global Plan to End TB produced by the Stop TB Partnership (6).
Funding available for TB prevention, diagnostic and treatment services
Data about funding available for TB prevention, diagnostic and treatment services by major category of expenditure and source of funding in the 9-year period 2015–2023 have been reported to WHO by 132 low and middle-income countries (LMICs) (Fig. 4.1.1). These countries accounted for 99% of reported TB cases globally in 2023.
Funding available for TB prevention, diagnostic and treatment services in LMICs falls far short of the global targets set at the 2023 UN high-level meeting, and has fallen since 2019. In 2023, the total funding available in LMICs was US$ 5.7 billion, equivalent to only 26% of the target of reaching US$ 22 billion by 2027. This level of funding in LMICs in 2023 was also lower than that the approximately US$ 6.0 billion that was available in each of the previous 3 years (2020–2022) (Fig. 4.1.2).
b The 132 countries accounted for 99% of the global number of notified cases of TB in 2023. In a small number of countries (seven countries in 2023, which accounted for 0.52% of the number of TB cases notified globally), TB funding data for 2023 were not reported to WHO and funding amounts could not be estimated from available data. For these countries, only the estimated financial costs associated with inpatient and outpatient treatment were included.
c In the most recent classification of countries by income group published by the World Bank (7), the Russian Federation was categorized as a high-income country. The country was included in all analyses because it was an upper-middle-income country for most of the period 2015–2023, it is in WHO’s list of high burden countries for drug-resistant TB and is one of the three countries in WHO’s list of global TB watchlist countries (having been in WHO’s list of high TB burden countries until 2020). For more details about WHO’s lists of high burden countries for TB, drug-resistant TB and TB/HIV, see Annex 3 of the core report document.
Explanations for the decline in the total amount of available
funding for 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 2); 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. While 2022–2023 saw an impressive rebound and further increase
in the number of people newly diagnosed and notified with TB (Fig. 2.1.1 in
Section 2.1), there was no comparable rebound in
the total funding available for TB service delivery. Instead, there was
a decrease in the total funding available between 2022 (US$ 6.0 billion)
and 2023 (US$ 5.7 billion); this was largely the result of reductions in
domestic funding in the BRICS (Brazil, the Russian Federation, India,
China, South Africa) group of countries, particularly in the Russian
Federation (Fig.
4.1.3). Overall, international donor funding for LMICs has
remained stable, at around US$ 1.2 billion per year.
Throughout the period 2015–2023, funding available by source shows a relatively consistent pattern in terms of the amounts and relative contributions from domestic and international donor sources (Fig. 4.1.2). In 2023, 80% of the funding available for TB prevention, diagnostic and treatment services was from domestic sources, similar to previous years. From 2019 to 2022, there was a decline in available funding from domestic sources (US$ 1.2 billion) and a very slight increase in funding provided by international donors (US$ 0.10 billion).
The main source of international donor funding for TB is The Global Fund (8). Its share of the total amount of international donor funding reported by NTPs to WHO was 76% in 2023. Section 4.2 provides a more comprehensive analysis, including additional funding that is not channeled through NTPs. 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, it contributes about 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 (Fig. 4.1.3). In combination, BRICS accounted for US$ 2.8 billion (63%) of the total of US$ 4.5 billion in 2023 that was provided from domestic sources. Overall, 97% of available funding in BRICS and all funding in Brazil, China and the Russian Federation in 2023 was from domestic sources. In other LMICs, international donor funding remains crucial. For example, in 2023 such funding accounted for 54% of the funding available in the 26 high TB burden and two global TB watchlist countries (Cambodia and Zimbabwe) outside BRICS, and 62% of the funding available in low-income countries (LICs).
a The two global TB watchlist countries included are Cambodia and Zimbabwe.
b Asia includes the WHO regions of South-East Asia and the Western Pacific.
c “Other regions” consists of three WHO regions: the Eastern Mediterranean Region, the European Region and the Region of the Americas.
b The three global TB watchlist countries are Cambodia, the Russian Federation and Zimbabwe (Annex 3 of the core report document).
Since 2017, the funding available for diagnosis and treatment of drug-susceptible TB has fallen slightly (Fig. 4.1.5). Funding available for treatment and management of drug-resistant TB increased from 2015–2022, but then declined in 2023; this pattern is largely explained by trends in the BRICS group of countries (Fig. 4.1.6).
b The category of drug-susceptible TB includes funding reported by NTPs for the following items: laboratory equipment and supplies; anti-TB drugs; programme management (including staff and activities); operational research and surveys; patient support; and miscellaneous items. It also includes WHO estimates of funding for inpatient and outpatient care for people treated for drug-susceptible TB, which are based on WHO estimates of the unit costs of bed-days and visits combined with the average number of outpatient visits and bed-days per TB patient as reported by NTPs.
c The category of drug-resistant TB includes funding reported by NTPs for the following items: anti-TB drugs required for treatment of multidrug and rifampicin-resistant TB (MDR/RR-TB, which includes people with pre-extensively drug-resistant TB and extensively drug-resistant TB, XDR-TB); any programme management (staff and activity) costs specifically required for the provision of care to people with drug-resistant TB; and WHO estimates of funding for inpatient and outpatient care. The categories for which funding is reported to WHO do not allow for funding for the diagnosis of drug-resistant TB specifically to be distinguished. In data analysis, the category of laboratory supplies and equipment is allocated to drug-susceptible TB. Rapid tests recommended by WHO can detect TB and RR-TB simultaneously.
d Data for TB preventive treatment (drugs only) are only available from 2019 onwards.
a The two global TB watchlist countries included are Cambodia and Zimbabwe.
b The category of drug-susceptible TB includes funding reported by NTPs for the following items: laboratory equipment and supplies; anti-TB drugs; programme management (including staff and activities); operational research and surveys; patient support; and miscellaneous items. It also includes WHO estimates of funding for inpatient and outpatient care for people treated for drug-susceptible TB, which are based on WHO estimates of the unit costs of bed-days and visits combined with the average number of outpatient visits and bed-days per TB patient as reported by NTPs.
c The category of drug-resistant TB includes funding reported by NTPs for the following items: anti-TB drugs required for treatment of multidrug and rifampicin-resistant TB (MDR/RR-TB, which includes people with pre-extensively drug-resistant TB and extensively drug-resistant TB, XDR-TB); any programme management (staff and activity) costs specifically required for the provision of care to people with drug-resistant TB; and WHO estimates of funding for inpatient and outpatient care. The categories for which funding is reported to WHO do not allow for funding for the diagnosis of drug-resistant TB specifically to be distinguished. In data analysis, the category of laboratory supplies and equipment is allocated to drug-susceptible TB. Rapid tests recommended by WHO can detect TB and RR-TB simultaneously.
Funding gaps for implementation of national strategic plans for TB
Data about required budgets and expected funding for the implementation of national strategic plans for TB, and associated sources of funding, are reported to WHO by NTPs as part of WHO’s annual rounds of global TB data collection. Funding gaps, as identified by NTPs, were estimated based on the difference between the required budget that was reported and the expected level of funding that was reported.
In 2024, 60 of the 132 LMICs reported that funding was not sufficient for full implementation of their national strategic plans for TB (Fig. 4.1.7).
The combined total of the funding gaps reported by 60 countries for 2024 amounted to US$ 1.7 billion. The largest gaps were reported by countries in the African and South-East Asia regions. Of the 26 LICs, 17 (65%) reported funding gaps that amounted to US$ 206 million in 2024 (Fig. 4.1.8).
Focusing on data from the 30 high TB burden countries and three global TB watchlist countries, Indonesia (US$ 294 million), Bangladesh (US$ 289 million), Nigeria (US$ 230 million), Viet Nam (US$ 138 million) and Kenya (US$ 121 million) reported the largest funding gaps (Fig. 4.1.9).
b The three global TB watchlist countries are Cambodia, the Russian Federation and Zimbabwe (Annex 3 of the core report document).
c Three countries i.e the Democratic People’s Republic of Korea, Papua New Guinea and Sierra Leone had not reported budget data for 2024 to WHO at the time the data snapshot for this webpage was taken (29 July 2024).
d Upper middle-income countries include one high-income country: the Russian Federation.
The Stop TB Partnership’s Global Plan to End TB (the Global Plan) for 2023–2030 estimated global funding needs of US$ 15–32 billion per year in LMICs. The estimated funding needs for 2024 were US$ 17 billion, of which US$ 2.1 billion was in LICs, US$ 9.7 billion was in lower-middle-income countries and US$ 5.3 billion was in upper-middle-income countries per year (6).
Overall, the total required budget reported by the 60 countries represented only 43% of the estimated needs in the Global Plan for LMICs in 2024 (Fig. 4.1.10). A likely explanation is that national strategic plans for TB are much less ambitious (in scale and scope) than the Global Plan. National plans will be influenced by known resource constraints, in terms of the funding available domestically and from international sources.
As an example, the reported funding gap in LICs (US$ 0.21 billion) is only around 12% of the gap (US$ 1.7 billion) between the estimated needs in the Global Plan for LICs (US$ 2.1 billion) and their expected level of funding in 2024 (US$ 0.37 billion) (6).
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. 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 Section 4.2 of this report).
Estimated cost per person treated for TB
The median cost per person treated for TB in 2023, from a provider perspective, was US$ 783 for drug-susceptible TB (Fig. 4.1.11).
Red dots indicate the 30 high TB burden and three global TB watchlist countries, blue dots indicate other countries; the size of each dot is proportional to the number of national notifications of drug-susceptible TB in 2023.
b Limited to countries with at least 100 persons on first-line treatment in 2023, that reported funding and utilisation data to WHO.
The median cost per person treated for drug-resistant TB, from a provider perspective, was US$ 4877 in 2023 (Fig. 4.1.12). These amounts include all of the provider costs associated with treatment and TB programme-related costs.
Red dots indicate the 30 high MDR/RR-TB burden countries, blue dots indicate other countries; the size of each dot is proportional to the number of national notifications of drug-resistant TB in 2023.
a The following costs are included: anti-TB drugs; programme management (staff and activity) costs specifically required for the provision of care to people with drug-resistant TB; inpatient and outpatient care.
b Limited to countries with at least 20 persons on second-line treatment in 2023, that reported funding and utilisation data to WHO.
Estimates of the costs incurred by people with TB and their households during diagnosis and treatment are available from national surveys (Section 5.2).
Further details about funding for TB prevention, diagnostic and treatment services are available in online country profiles and the Global Tuberculosis Report mobile app. Methods for data collection and analysis are summarized below (Box 4.1).
Box 4.1
Methods used to compile, review, validate and analyse financial data reported to WHO
WHO began monitoring government and international donor financing for TB prevention, diagnostic and treatment services in 2002. All data are stored in the WHO global TB database. The standard methods used to compile, review, validate and analyse these data are described in detail in a technical appendix; this box provides a summary.
The methods used to systematically review and validate data have remained consistent since 2002. They include routine checks for plausibility and consistency, and discussions with country respondents to resolve queries. In reviewing and validating data, particular attention has always been given to high TB burden countries.
Missing data are handled as follows:
The analysis of available funding for TB uses reported information on received funding. When received funding is not available for a given year, expenditure data are used. If data on received funding and expenditure are both unavailable, data on committed funds are used. If none of these data are available, received funding, expenditure or committed funds from adjacent years are used. For analysis of funding in 2023, received funding was replaced by one of these methods in 30 countries, which collectively accounted for 2.1% of the global number of notified cases of TB in 2023 (this included two high burden countries, the Democratic People’s Republic of Korea and Sierra Leone, which in combination accounted for 1.2% of the global number of TB case notifications). Seven countries (collectively accounting for 0.52% of the global number of notified cases of TB in 2023) did not have sufficient data for any of the above methods to be applied; the estimated financial costs associated with inpatient and outpatient treatment were the only components included for these countries, using the methods described below.
When the breakdown of received funding by source or by category are missing for a given year, country-specific shares from the previous year are applied instead.
Since TB funding reported by NTPs does not usually include the financial costs associated with the inpatient and outpatient care required during TB treatment (exceptions among high TB or MDR/RR-TB burden countries include Belarus, China, Kazakhstan and the Russian Federation), country-specific estimates of the funding required for both inpatient and outpatient care are added. This is done by multiplying the reported number of TB patients notified by the product of the average number of bed days and outpatient visits per patient (as reported by NTPs) and their respective unit costs; this is done separately for TB patients with drug-susceptible TB and drug-resistant TB. Unit costs are estimated using the WHO CHOosing Interventions that are Cost-Effective (WHO-CHOICE) methods. Estimates of the costs of inpatient and outpatient care are produced for people with drug-susceptible TB and MDR/RR-TB separately.
Trend data are shown in constant (as opposed to current) 2023 US
dollars. In other words, funding amounts are shown in real terms, after
adjustment for inflation. Figures and tables that show data for 2023
only are labelled as current 2023 US dollars.
References
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