Financing tuberculosis control: promising trends and remaining challenges
Authors: Anna Vassall, Michelle Remme
Journal: The Lancet Global Health (2013)

The financing of essential health services for the world's poor is changing. Development assistance to health (DAH) seems to be flat-lining, and use of domestic resources and value for money are increasingly emphasised.1Leach-Kemon K Chou DP Schneider MT et al.The global financial crisis has led to a slowdown in growth of funding to improve health in many developing countries.Health Aff (Millwood). 2012; 31: 228-235Crossref PubMed Scopus (94) Google Scholar, 2WHOWorld health report. Health systems financing: the path of universal coverage. World Health Organization, Geneva2010Google Scholar Many development agencies are re-examining thematic and geographic priorities and implementing new cofinancing agreements. The Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, now requires 5–60% counterpart financing, depending on a country's income.3Global Fund To Fight AIDSTuberculosis and MalariaPolicy on eligibility criteria, counterpart financing requirements, and prioritization of proposals for funding from the Global Fund. Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva2011Google Scholar Ensuring that scarce development funds flow at a sufficient scale to effective interventions that serve people who need them most remains a challenge. Much previous work highlights the rapid increases in DAH in the past decade,4Ravishankar N Gubbins P Cooley RJ et al.Financing of global health: tracking development assistance for health from 1990 to 2007.Lancet. 2009; 373: 2113-2124Summary Full Text Full Text PDF PubMed Scopus (378) Google Scholar but in The Lancet Global Health, Katherine Floyd and colleagues5Floyd K Fitzpatrick C Pantoja A Raviglione M Domestic and donor financing for tuberculosis care and control in low-income and middle-income countries: an analysis of trends, 2002–11, and requirements to meet 2015 targets.Lancet Glob Health. 2013; 1: e105-e115Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar report that, in the case of tuberculosis, growth in domestic financing has been equally impressive. Their findings are convincing, especially in view of the fact that their study might underestimate domestic contributions because some health systems expenditures and costs incurred by patients outside formal tuberculosis services are excluded. Domestic funding for tuberculosis increased by more than 160% in 9 years to reach US$3·9 billion in 2011, driven mostly by Brazil, Russia, India, China, and South Africa (BRICS), which, in 2011, paid for more than 95% of their yearly tuberculosis bills. UNAIDS reports a similar trend in HIV spending—BRICS increased domestic expenditure by more than 120% between 2006 and 2011, and now fund more than 75% of their HIV responses.6UNAIDSMeeting the investment challenge—tipping the dependency balance. Joint United Nations Programme on HIV/AIDS, Geneva2012Google Scholar These findings are important and support the reorientation of DAH towards the poorest countries, although much work remains to be done to reduce the costs of tuberculsosis borne by poor patients and their families in middle-income countries.7Rajeswari R Balasubramanian R Muniyandi M Geetharamani S Thresa X Venkatesan P Socio-economic impact of tuberculosis on patients and family in India.Int J Tuberc Lung Dis. 1999; 3: 869-877PubMed Google Scholar This encouraging global picture needs to be balanced with the substantial resource gap that remains (mainly in low-income countries). Floyd and colleagues estimate that an additional $1·6–2·3 billion of DAH a year is needed for a comprehensive global response to the tuberculosis epidemic, and even this amount might be an underestimate. Countries might not be able to expand health expenditure at the same pace as general government expenditure, and much of the domestic contribution to tuberculosis services is funding for general health services. Core health systems can take time to expand because of investment constraints, such as the time needed to train new health workers. Furthermore, although costs might be reduced as coverage expands (economies of scale), detection of cases of tuberculosis that are not being reached through the health system and incorporation of new technologies might increase costs. Finally, increasing DAH could substitute for and reduce domestic funding.8Lu C Schneider MT Gubbins P Leach-Kemon K Jamison D Murray CJL Public financing of health in developing countries: a cross-national systematic analysis.Lancet. 2010; 375: 1375-1387Summary Full Text Full Text PDF PubMed Scopus (287) Google Scholar Floyd and colleagues' data suggest that, in low-income and lower-middle-income countries, domestic funding as a proportion of total funding fell by 6–10%, supporting the need for cofinancing agreements in the future. The investment case for tuberculosis control is as sound as ever. The foundations are strong. Floyd and coworkers' findings emphasise that tuberculosis services are highly cost-effective, not only in trial settings, but also on a global scale. At a cost as low as $100 per patient successfully treated in high-burden countries, tuberculosis control remains as good value as ever. However, for a disease that still causes more than 1·2 million deaths every year, funding for tuberculosis fares badly compared with the $16·8 billion spent on HIV/AIDS, which caused 1·47 million deaths in 2011.6UNAIDSMeeting the investment challenge—tipping the dependency balance. Joint United Nations Programme on HIV/AIDS, Geneva2012Google Scholar, 9Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (10100) Google Scholar Global and national institutions working in tuberculosis therefore have much to do to ensure that DAH is allocated on the basis of the best available evidence for cost-effectiveness. Making the case for further expansion of treatment for multidrug-resistant tuberculosis and more intensive screening will not necessarily be easy. Although both might be cost effective, arguing for more resources to expand the the package of tuberculosis services will be challenging for countries struggling to ensure effective case detection and DOTS coverage. Lessons can be learned from work in HIV, in which increased attention is focused on the potential benefits of releasing additional funding for service delivery through increased efficiency.10Schwartländer B Stover J Hallett T et al.Towards an improved investment approach for an effective response to HIV/AIDS.Lancet. 2011; 377: 2031-2041Summary Full Text Full Text PDF PubMed Scopus (363) Google Scholar Floyd and colleagues suggest that tuberculosis costs are driven mainly by country income level and caseload. However, within countries, cost variation in health services can be substantial,11Obure CD Vassall A Michaels C et al.Optimising the cost and delivery of HIV counselling and testing services in Kenya and Swaziland.Sex Transm Infect. 2012; 88: 498-503Crossref PubMed Scopus (25) Google Scholar yet little is known about the extent of inefficiency within tuberculosis services. Furthermore, in the future, new, shorter drugs regimens, if proven efficacious and appropriately priced, could reduce costs to both the health system and patients. Although Floyd and colleagues should be congratulated for their succinct summary of the financing of tuberculosis control, much work remains to ensure that poor people no longer have to bear both the economic and health burden of this preventable and treatable disease. We declare that we have no conflicts of interest. Domestic and donor financing for tuberculosis care and control in low-income and middle-income countries: an analysis of trends, 2002–11, and requirements to meet 2015 targetsFunding for tuberculosis control increased substantially between 2002 and 2011, resulting in impressive and cost-effective gains. The increasing self-sufficiency of many countries, including BRICS, which account for almost half the world's tuberculosis cases, is a success story for control of tuberculosis. Nonetheless, international donor funding remains crucial in many countries and more is needed to achieve 2015 targets. Full-Text PDF Open Access