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 in 2002; findings have been published in global TB reports and peer-reviewed publications (1–3). Funding data for 2010–2020 have been reported to WHO by 137 low- and middle-income countries (LMICs), which accounted for 98% of reported TB cases globally in 2020 (Fig. 5.1). 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$ 8.9 billion was required for TB prevention, diagnostic and treatment services in LMICs in 2018, rising to US$ 13.4 billion in 2020 and US$ 15.5 billion in 2022 (5) (Fig. 5.2). 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.

Funding for TB prevention, diagnostic and treatment services continues to fall far short of the globally estimated need and the UN global target (Fig. 5.2, Fig. 5.3, Fig. 5.4). Although funding increased between 2010 and 2014, from US$ 5.2 billion to US$ 6.1 billion, it then declined to US$ 5.3 billion in 2016 and subsequently plateaued at around US$ 5.8 billion per year from 2017 to 2019 (Fig. 5.3, Fig. 5.4). In 2020, global spending on TB services fell for the first time since 2016, to US$ 5.3 billion (an 8.7% fall between 2019 and 2020). This is less than half (39%) of the amount estimated to be required in the Global Plan and less than half (41%) of the global target set at the UN high-level meeting on TB.

The decline in spending between 2019 and 2020 likely reflects several factors. These include an 18% reduction in the global number of people reported as diagnosed with TB between 2019 and 2020 (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. Together, these factors mean that spending on outpatient and inpatient care for people diagnosed with TB fell by about US$ 0.4 billion between 2019 and 2020.

As in the past 2 decades, most of the funding available in 2020 (US$ 4.3 billion out of a total of US$ 5.3 billion; i.e. 81%) was from domestic sources (Fig. 5.5). This aggregate figure for 137 LMICs was strongly influenced by the BRICS group of countries (Brazil, Russian Federation, India, China and South Africa), which together accounted for US$ 2.8 billion (65%) of the US$ 4.3 billion domestic funding available in 2020 (Fig. 5.6). Overall, 95% of the available funding in BRICS and all funding in Brazil, China and the Russian Federation was from domestic sources.

In other LMICs, international donor funding remains crucial (Fig. 5.6). For example, such funding accounted for 53% of the funding available in the 26 high TB burden and two global TB watchlist countries (Cambodia and Zimbabwe) outside BRICS, and 59% of the funding available in low-income countries (LICs) in 2020. In the former group, Bangladesh and Zambia are examples of high TB burden countries that have steadily increased domestic funding specifically allocated for TB (as opposed to funding allocated more generally for inpatient and outpatient care, including for people with TB) since 2015 (by 7-fold) (Fig. 5.7).

The total amount of international donor funding per year averaged US$ 0.9 billion in the period 2010–2020, with some fluctuation (Fig. 5.5). It rose between 2010 and 2013 (from US$ 0.7 billion to US$ 1.0 billion), fell back slightly in 2014 and 2015, peaked in 2017 (at US$ 1.1 billion) and subsequently stabilized at US$ 1.0 billion per year between 2018 and 2020.

The main source of international donor funding is the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), with a contribution that ranged from 69% (in 2010) to 83% (in 2017) of the total; in 2020, it was 76% (equivalent to US$ 0.8 billion, 15% of the total of US$ 5.3 billion spent globally). As a share of the total funding reported as required for full implementation of national strategic plans for TB, funding from the Global Fund amounted to 39% of the need in LICs, 33% of the need in lower-middle income countries and 2% of the need in upper middle-income countries. The United States Government is the largest contributor of funding to the Global Fund and also the largest bilateral donor; overall, it contributes close to 50% of international donor funding for TB.

Of the total US$ 5.3 billion available in 2020, US$ 3.2 billion was for diagnosis and treatment of drug-susceptible TB and US$ 2.0 billion was for diagnosis and treatment of multidrug- or rifampicin-resistant TB (MDR/RR-TB) (Fig. 5.3). Both these amounts are less than half (38% and 45%, respectively) of the requirements estimated in the Global Plan (US$ 8.5 billion and US$ 4.4 billion in 2020, respectively) (Fig. 5.2). Since 2010, funding for diagnosis and treatment of drug-susceptible TB has fallen slightly (from a baseline of US$ 4.0 billion) and funding for MDR/RR-TB has more than doubled (from a baseline of US$ 0.9 billion). This growth is largely explained by trends in BRICS (Fig. 5.8), which accounted for 71% of total funding for MDR/RR-TB in the period 2010–2020, and for 54% of the total number of people with MDR/RR-TB who were diagnosed and reported in 2020. The remaining amount (<US$ 0.1 billion) includes funding for TB preventive treatment (covering drugs only) and interventions specifically related to HIV-associated TB.

In 2020, 70 of the 137 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$ 318 million), Nigeria (US$ 268 million), the Philippines (US$ 152 million) and China (US$ 109 million). Of the 27 LICs, 18 reported funding gaps that amounted to US$ 151 million in 2020.

The funding gaps reported by countries fall far short of the gap between the needs estimated in the Global Plan and the amount of funding available in 2020. For example, in LICs the gap between the needs estimated in the Global Plan and the amount of funding available in 2020 was US$ 1.3 billion (US$ 1.6 billion compared with US$ 0.3 billion). 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.

To accelerate progress towards mobilizing the funding needed to reach the UN high-level meeting target of at least US$ 13 billion per year by 2022 (Fig. 5.4) and the requirements set out in the Global Plan (Fig. 5.2), increases in both domestic and international funding for TB are urgently required. The single largest source of funding (76% of the total in 2020) is the Global Fund, so allocations by the Global Fund will be the dominant influence on international donor funding for TB.

Provisional data suggest that allocations for 2021 will remain inadequate. For example, international donor funding reported by national TB programmes (NTPs) is expected to grow by only US$ 147 million between 2020 and 2021. It is possible that this amount may increase through new funding from the Global Fund’s COVID-19 Response Mechanism (C19RM). To date, about US$ 100 million has been allocated for TB through the C19RM. Upcoming applications to the Global Fund (e.g. from the Democratic Republic of the Congo, Indonesia, India, Mozambique, Pakistan and South Africa) may result in additional funding. 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).

The median cost per person treated for TB in 2020 was US$ 1245 for drug-susceptible TB (Fig. 5.11) and US$ 3868 for MDR/RR-TB (Fig. 5.12). These amounts include all of the provider costs associated with treatment. 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 online country profiles and the Global Tuberculosis Report mobile app. Methods for data collection and analysis are described in a technical annex.

The Stop TB Partnership is currently developing a Global Plan to End TB, 2023–2030, which will include updated estimates of resource requirements.

Fig. 5.1 The 137 low- and middle-income countries included in analyses of TB financing, 2010–2020

Fig. 5.2 Estimates of funding required for TB prevention, diagnostic and treatment services in 129 low- and middle-income countries^a, in the Global Plan to End TB 2018–2022

Fig. 5.3 Funding for TB prevention, diagnostic and treatment services in total and by category of expenditure, 2010–2020, 137 countries with 98% of reported TB cases in 2020

Fig. 5.4 Funding for TB prevention, diagnostic and treatment services for 137 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, 2015–2020

Fig. 5.5 Funding for TB prevention, diagnostic and treatment services by funding source, 2010–2020, 137 countries with 98% of reported TB cases in 2020

Fig. 5.6 Funding for TB prevention, diagnostic and treatment services from domestic sources and international donors, 2010–2020, 9 country groups

Fig. 5.7 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, 2010–2020^a

Fig. 5.8 Funding for drug-susceptible TB and MDR/RR-TB, 2010–2020, three country groups

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, 2010–2020

The total reported gap in 2020 amounted to US$ 1.6 billion

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, 2020^a

Fig. 5.11 Estimated cost per patient treated for drug-susceptible TB in 122 countries, 2020^a

Fig. 5.12 Estimated cost per patient treated for MDR/RR-TB in 104 countries, 2020^a