Treatment coverage and reducing the tuberculosis burden in low-income and middle-income counties
Authors: Deepak Kumar Behera
Journal: The Lancet Global Health (2022)

Tuberculosis incidence has been reducing at the global level from 164 cases per 100 000 population in 1990 to 109 cases per 100 000 population in 2019, while the mortality rate has also decreased from 33 deaths per 100 000 population to 15 deaths per 100 000 population in the same period.1Global Burden of Disease Collaborative NetworkGlobal Burden of Disease Study 2019 (GBD 2019) results. Institute for Health Metrics and Evaluation (IHME), Seattle, WA2020https://ghdx.healthdata.org/gbd-results-toolDate accessed: March 12, 2022Google Scholar These decreasing trends were also seen in low-income and middle-income countries (LMICs).2Ledesma JR Ma J Vongpradith A et al.Global, regional, and national sex differences in the global burden of tuberculosis by HIV status, 1990–2019: results from the Global Burden of Disease Study 2019.Lancet Infect Dis. 2022; 22: 222-241Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar However, less is known about the role of disease-specific spending on disease outcomes.3Hussey PS de Vries H Romley J et al.A systematic review of health care efficiency measures.Health Serv Res. 2009; 44: 784-805Crossref PubMed Scopus (147) Google Scholar Therefore, Gerard Joseph Abou Jaoude and colleagues4Abou Jaoude GJ Garcia Baena I Nguhiu P et al.National tuberculosis spending efficiency and its associated factors in 121 low-income and middle-income countries, 2010–19: a data envelopment and stochastic frontier analysis.Lancet Glob Health. 2022; 10: e649-e660Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar did a data envelopment and stochastic frontier analysis, published in The Lancet Global Health, to examine how tuberculosis spending efficiency could improve health outcome (ie, treatment coverage) in a sample of 121 LMICs from 2010 to 2019. Abou Jaoude and colleagues found a positive association between spending efficiency and tuberculosis treatment coverage while maintaining the same level of spending allocation. This study has some uniqueness that makes it a valuable addition to the literature. First, the application of advanced econometric models that include data envelopment analysis and stochastic frontier analysis provides an average value of spending efficiency in LMICs. Second, the adoption of government commitment and universal health coverage indicators provides a new parameter for the evaluation of the efficiency of the health system. Third, it provides a framework for efficiency analyses of other disease-specific spending and to assist governments in prioritising spending for disease-specific programmes. Finally, a similar analysis could be possible at the individual country and subnational level for the successful implementation of tuberculosis programmes. Despite the uniqueness, a few issues have not been addressed in the study. First, the study did not include government commitment or prioritised health spending indicators5McIntyre D Kutzin J WHOHealth financing country diagnostic: a foundation for national strategy development. World Health Organization, Geneva2016Google Scholar (ie, government health expenditure as a proportion of general government expenditure and government health expenditure as a proportion of total health expenditure). Second, this study has found a positive association between tuberculosis disease outcome and public health spending efficiency by using aggregate data in LMICs. However, the authors have not done any tests of robustness of the empirical results by using disaggregate data that includes country classification per income or disease prevalences. Disaggregated analysis could provide improved insights on this aspect by controlling country-specific effects.6WHOWHO global lists of high burden countries for tuberculosis (TB), TB/HIV and multidrug/rifampicin-resistant TB (MDR/RR-TB), 2021–2025. World Health Organization, Geneva2021https://apps.who.int/iris/bitstream/handle/10665/341980/9789240029439-eng.pdfDate accessed: March 12, 2022Google Scholar Abou Jaoude and colleagues4Abou Jaoude GJ Garcia Baena I Nguhiu P et al.National tuberculosis spending efficiency and its associated factors in 121 low-income and middle-income countries, 2010–19: a data envelopment and stochastic frontier analysis.Lancet Glob Health. 2022; 10: e649-e660Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar also suggest that alternative sources of revenue and spending efficiency can improve health outcomes and achieve health-related Sustainable Development Goals by 2030. This study offers suggestions on how a country with restricted fiscal space for health might minimise use of resources through efficient use of existing funds and resources. Because limited fiscal space is a major issue in LMICs to mobilise increased funds to health-care services, methods to generate alternative resources to reduce the fiscal gap among countries is a new policy discourse in health financing literature.7Barroy H Sparkes S Dale E WHOAssessing fiscal space for health expansion in low-and-middle income countries: a review of the evidence. World Health Organization, Geneva2016Google Scholar Therefore, Abou Jaoude and colleagues’ study has practical implications for resource-poor economies to achieve health-related goals and targets using a cost-effective spending strategy. This study delivers an important message to undertake a similar type of health efficiency analysis in the future. The inclusion of governance, demographic, socioeconomic, and fiscal spending parameters provides a selection of confounding factors through which countries could achieve improved efficiency scores. Additionally, the application of advanced statistical models by controlling multicollinearity, heteroscedasticity, and unobserved heterogeneity among countries can provide an improved estimate for resource allocation for health. I declare no competing interests. National tuberculosis spending efficiency and its associated factors in 121 low-income and middle-income countries, 2010–19: a data envelopment and stochastic frontier analysisTo improve efficiency, treatment coverage will need to be increased, particularly in the least efficient contexts where this might require additional spending. However, progress towards global End TB targets is slow even in the most efficient countries. Variables associated with TB spending efficiency suggest efficiency is complimented by commitments to improving health-care access that is free at the point of use and wider progress towards the SDGs. These findings support calls for additional investment in tuberculosis care. Full-Text PDF Open Access