Abrupt reductions in global health funding for tuberculosis (TB) could impose tens of billions of dollars in additional costs on affected households in low- and middle-income countries (LMICs), with the heaviest burden falling on the poorest families, according to a modeling study published yesterday in PLOS Medicine.
Using linked epidemiologic and economic models tailored to 79 LMICs, which represent 91% of the world’s TB cases, US and UK researchers projected the household financial consequences of several funding-cut scenarios from 2025 through 2050. The scenarios reflect potential termination of US Agency for International Development (USAID) support—80% to 90% of which was cut last year—and varying levels of reductions in contributions to the Global Fund to Fight AIDS, TB, and Malaria.
The study did not assess the impact of funding cuts on illness and deaths. TB is the world’s leading cause of infectious disease deaths, attributed to an estimated 1.25 million fatalities in 2023.
Poorest households hit hardest
Under a scenario in which USAID funding alone is terminated beginning in 2025, TB-affected households would face an estimated $7.5 billion (95% uncertainty interval [UI]: $6.1 billion to $8.9 billion) in additional patient-incurred costs over 25 years. An additional 3.9 million (95% UI, 3.1 million to 4.6 million) additional households would experience “catastrophic costs,” defined by the World Health Organization as TB-related expenses exceeding 20% of annual household income.
When the researchers modeled more severe scenarios, the estimated impacts grew substantially. If the US were to terminate both USAID support and all Global Fund contributions, total additional patient-incurred costs would reach $24 billion (95% UI, $19.2 billion to $28.5 billion).
In the most extreme scenario in which all external TB funding is eliminated, households would incur $79.7 billion (95% UI, $60.0 billion to $99.2 billion) in added costs, and an estimated 40.5 million (UI, 30.9 million to 50.7 million) additional households would face catastrophic costs, a 32% increase over baseline projections.
Although higher-income quintiles accounted for just over half of total increased costs (due to higher per-episode spending), the largest absolute increases in catastrophic costs occurred among poorer households. Across scenarios, nearly 60% of additional catastrophic-cost cases occurred in the poorest two income quintiles, with roughly two-thirds of cases concentrated in the poorest 20% of households across countries.
Economic toll could far outweigh vaccine benefits
To illustrate the scale of the projected losses, the authors compared their findings with earlier estimates of the economic benefits associated with a new TB vaccine.
“The magnitude of these impacts can be compared to a prior analysis estimating the potential health gains from a novel TB vaccine over 2028–2050,” they write. “This earlier analysis estimated that new vaccine introduction could avert US$38 to US$44 billion in patient-incurred costs, with 23 million fewer households facing catastrophic costs due to TB. Based on this comparison, the potential negative consequences of reduced international donor funding for TB are almost double the potential benefits from a novel TB vaccine.”
Since early 2025, major donor funding for LMICs has already shifted and disrupted services. Continued withdrawal of donor support could further erode access to health care, especially for the poorest households, the researchers write. They call for strategies to protect vulnerable populations if donor funding continues to decline.
