Understanding spending trends for tuberculosis
Authors: Alice Zwerling
Journal: The Lancet Infectious Diseases (2020)

As the tuberculosis community strives to work towards tuberculosis elimination goals, financing and spending continue to be crucial issues.1WHOThe End TB Strategy: global strategy and targets for tuberculosis prevention care and control after 2015. World Health Organization, Geneva2014https://www.who.int/tb/post2015_strategy/en/Date accessed: April 8, 2020Google Scholar Tuberculosis usually affects the most poor and vulnerable populations and resources have always been few and strained.2Floyd 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 (43) Google Scholar Year after year, reports from WHO, STOP TB, and other advocacy groups show that tuberculosis spending is inadequate to diagnose and treat existing cases, and recent meetings such as the 2018 UN high-level meeting on tuberculosis have elicited pledges to improve resources and finances available in the fight against tuberculosis.3Treatment Action GroupTuberculosis research funding trends 2005–2018. Stop TB Partnership, New York, NY2019Google Scholar, 4UNPolitical declaration of the UN general assembly high-level meeting.https://digitallibrary.un.org/record/1649568?ln=enDate: 2018Date accessed: April 15, 2020Google Scholar Such pledges might become even more crucial as resources, funding, and manpower initially dedicated towards tuberculosis control efforts are redirected to support efforts to fight the coronavirus disease 2019 (COVID-19) pandemic, which is now affecting many, if not all, high tuberculosis burden countries. Modelling analyses, such as the one published in The Lancet infectious Diseases by Yangfang Su and colleagues,5Su Y Garcia Baena I Harle AC et al.Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000–17: a financial modelling study.Lancet infect Dis. 2020; (published online April 23.)https://doi.org/10.1016/S1473-3099(20)30124-9Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar provide useful information to assess and monitor total tuberculosis spending across low-income and middle-income countries. In their study, Su and colleagues used modelling techniques from the Global Burden of Diseases study to generate comprehensive estimates of total tuberculosis spending from all sources across 135 low-income and middle-income countries between 2000 and 2017, allowing for comparisons across countries and over time. The authors estimate total spending for both notified and non-notified cases. These data can be helpful in understanding financial contributions from different sources including government, pre-paid private spending, out-of-pocket medical expenses, and development assistance for health funding, and in capturing the burden experienced by households and communities not typically captured by more traditional reports focused only on notified cases and government and donor spending. They also disaggregated spending estimates by function (eg, outpatient visits, pre-diagnosis visits, private drug spending). Su and colleagues found that total tuberculosis spending increased for 2000–17, driven primarily by government and national tuberculosis programme spending on notified cases, and that spending on non-notified cases also increased. Total out-of-pocket spending decreased over the same period; however, although the authors captured direct out-of-pocket spending on medical expenses, they did not include non-medical costs including loss of income, transport, and indirect economic costs due to tuberculosis (many of which are now being collected through WHO patient cost surveys) in their analysis. The authors' findings show that three countries with strong private sectors—Democratic Republic of the Congo, Nigeria, and Pakistan—have out-of-pocket medical expenses as the primary source of tuberculosis spending. Prepaid private and out-of-pocket spending contributions were found to be relatively small and that many governments in low-income and middle-income countries finance most national spending on tuberculosis. Several, but not all, high tuberculosis burden countries were middle-income countries and cost data is often skewed, driven by increased costs in these countries—eg, average outpatient visits were estimated to cost US$35·92 per visit, while the median cost was only $4·24 per visit, meaning that in half of the countries the cost per visit was lower than $4·24. Conversely many high tuberculosis burden low-income countries are still heavily reliant on development assistance for health spending. Notably, the authors present mean values weighted by population size or number of incident cases for the region, which is in line with the larger global burden of disease approach; however, such presentation requires careful interpretation. For instance, when looking at data for a specific country, the average total spend per incident case might be driven up by a few key countries in that region with large populations or numbers of incident cases, or both. Although the results might be an overestimation or underestimation of specific estimates, extensive sensitivity analyses done by the authors show that the qualitative results are robust. Therefore, trends over time and across countries can be used to monitor fluctuations in total tuberculosis spending and assess needs across regions. This work also raises many important questions around reasons for changes in tuberculosis spending trends. Future work in this area should investigate reasons why tuberculosis spending levels have changed over time, with a particular focus on understanding decreasing costs in specific countries. I declare no competing interests. Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000–17: a financial modelling studyDespite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending. Full-Text PDF Open Access