TB and health financing

Tuberculosis (TB), as an airborne infectious disease, demands a comprehensive public health response beyond just clinical treatment. While individual health actions (IHAs) focus on diagnosis and treatment, public health actions (PHAs) address broader population-level concerns, such as case-finding and prevention. Without PHAs, many TB cases remain undetected—particularly in high-burden countries where surveys show that a significant number of patients never seek formal care. Additionally, health facilities often miss cases due to a lack of proactive screening. This gap not only perpetuates transmission but also contributes to higher morbidity and mortality.

Proactive measures like private provider engagement, community screening, and targeted interventions in high-risk settings (e.g., prisons, mines) significantly improve case detection. Furthermore, PHAs also include actions to ensure treatment completion and prevent drug resistance, such as follow-up mechanisms, social protection payments, and contact investigations. These interventions require deliberate planning and financing, often relying heavily on donor support. However, sustainable TB control necessitates that countries take ownership and include PHAs in their broader health financing strategies, especially as patients may prematurely discontinue treatment, risking relapse and transmission.

Health financing for TB has traditionally centered on IHAs, leaving PHAs underfunded. In low-income countries, governments often fund public facilities directly through supply-side financing, with international donors filling gaps for PHAs. As countries transition toward demand-side financing through social health insurance (SHI), integrating TB services—including both medical and non-medical components—into SHI and social protection schemes becomes essential. This integration not only reduces catastrophic costs for patients but also strengthens outcomes. Yet, it requires political commitment and structural adjustments in budgeting practices.

Resource mobilization must go beyond simple calls for increased funding. National TB programs (NTPs) need to map and align diverse domestic financing sources to cover both IHAs and PHAs. This includes determining which government levels are responsible for funding community health workers and public health programs, whether commodities should remain under NTP control or shift to SHI, and exploring co-financing models between central and subnational entities. A strategic, multisectoral approach ensures that TB financing reflects the program’s full scope and complexity.

Contracting NGOs and private sector actors for specific TB services has proven effective, especially for community outreach and engagement. However, many such arrangements are donor-dependent, lacking sustainability. Countries like Bangladesh and India are pioneering transitions to domestically funded contracting, developing the necessary infrastructure and tools for contract management. These efforts include defining service packages, establishing legal frameworks, and building government capacity for procurement and payment oversight. Though lessons from HIV programs are useful, TB presents unique challenges, requiring tailored contracting models to ensure effective service delivery and program longevity.

Source: Wells, W.A., Waseem, S. and Scheening, S., 2024. The intersection of TB and health financing: defining needs and opportunities. IJTLD open, 1(9), pp.375-383.