# The potential impact of reduced international donor funding on the household economic burden of tuberculosis in low- and middle-income countries: A modeling study

## TL;DR

This study models how reduced international funding for tuberculosis could increase financial hardship for poor households in low- and middle-income countries.

## Contribution

The study introduces a novel modeling approach to estimate the economic impact of donor funding cuts on tuberculosis patients in low- and middle-income countries.

## Key findings

- Ending USAID funding alone could add $7.5 billion in patient costs and 3.9 million additional households facing catastrophic costs.
- Eliminating all external funding could result in $79.7 billion in additional costs and 40.5 million more households with catastrophic costs.
- The poorest 20% of households would bear over 50% of the additional catastrophic costs.

## Abstract

Recent shifts in the global health funding landscape—most notably the dismantling of the United States Agency for International Development (USAID) and possible reduced contributions to the Global Fund to Fight AIDS, TB, and Malaria (Global Fund)—threaten essential tuberculosis (TB) services in low- and middle-income countries (LMICs). We quantified the potential impact on the household economic burden of TB.

We used linked epidemiological and economic models, calibrated to 79 LMICs, to estimate future TB patient costs under six scenarios: continuation of 2024 funding levels (baseline), termination of USAID, termination of USAID plus announced reductions in Global Fund contributions from the USA alone, termination of USAID plus complete termination of Global Fund contributions from the USA alone, termination of USAID plus announced reductions in Global Fund contributions from all donor countries contributing 1% or more to the budget, and full elimination of external funding for TB. Outcomes included total TB-attributable household costs and numbers of households experiencing catastrophic costs (disease-related costs >20% of annual income). USAID termination was projected to produce US$7.5 (95% uncertainty interval: $6.1–8.9) billion in additional patient-incurred costs and 3.9 (3.1–4.6) million additional households experiencing catastrophic costs over 2025–2050. The worst-case scenario (elimination of all external funding) resulted in $79.7 ($60.0–99.2) billion in additional patient-incurred costs and 40.5 (30.9–50.7) million additional households experiencing catastrophic costs—a 32% increase over baseline. Impacts were greatest for poorer households, with over 50% of additional catastrophic costs occurring in the poorest 20% of households. This analysis is limited by substantial uncertainty regarding costs faced by untreated patients and assumptions of constant patient costs and uniform treatment reductions over time.

Abrupt reductions in international donor funding for TB may reverse recent progress toward financial risk protection and health equity in LMICs. Strategies to reduce the disruption caused by funding cuts and protect vulnerable populations are urgently needed.

Tuberculosis can result in substantial medical costs and income loss that can threaten financial security for affected families in low- and middle-income countries (LMICs).

International donor funding has played a major role in reducing both cases of tuberculosis and the associated financial burden on households, but recent policy changes have put this funding at risk.

This study estimated how reductions in donor funding could affect the economic burden of tuberculosis on patients, especially among the poorest households.

We adapted a system of linked epidemiological and economic models covering 79 LMICs to estimate tuberculosis-affected household costs under several scenarios of reduced international funding between 2025 and 2050.

Ending funding for tuberculosis testing and treatment from the United States Agency for International Development alone was estimated to result in an additional 7.5 billion US dollars in patient costs and nearly 4 million more households experiencing catastrophic costs.

In the most severe scenario, eliminating all external funding for tuberculosis could lead to nearly 80 billion US dollars in additional household costs and more than 40 million extra households facing catastrophic costs, with the largest impacts falling on the poorest households.

Large and sudden reductions in international funding for tuberculosis could reverse progress in protecting families from severe financial hardship, particularly among the poorest populations.

The findings highlight the importance of maintaining stable financing for tuberculosis testing and treatment services or developing alternative funding strategies to protect vulnerable households.

This analysis is limited by substantial uncertainty regarding costs faced by untreated patients and assumptions of constant patient costs and uniform treatment reductions over time.

In a modelling study, Allison Portnoy and colleagues investigate the potential impact of reduced international donor funding on the household economic burden of Tuberculosis in low- and middle-income countries.Image: https://pixabay.com/illustrations/debt-money-credit-loan-mortgage-3272735/Credit: Tumisu via Pixabay