The potential impact of reduced international donor funding on the household economic burden of tuberculosis in low- and middle-income countries
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Background
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.
Methods
We used linked epidemiological and economic models, calibrated to 79 LMICs, to estimate future TB patient costs under four scenarios: continuation of 2024 funding levels (baseline), termination of USAID, termination of USAID plus announced reductions in Global Fund contributions, 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).
Findings
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.
Interpretation
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.
Research in context
Evidence before this study
Several prior studies have examined the potential impact of cuts in international health funding from the United States of America. We searched PubMed and medRxiv for studies quantifying the effects of reductions in international donor funding on the economic burden of tuberculosis, published between January 1 and August 7, 2025, using search terms related to funding (“funding”, “donor”, “aid”, “assistance”), tuberculosis (“tuberculosis”, “TB”), patients or households (patient*, household*), and economic burden (cost*, econ*). The identified studies described a range of potential health consequences that could result from funding cuts. To our knowledge, no studies have considered the impact of funding cuts on the household economic burden of disease.
Added value of this study
Our modelling suggested that termination of United States Agency for International Development (USAID) funding could lead to 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. Further reductions in funding to the Global Fund to Fight AIDS, TB and Malaria (Global Fund) in line with current announcements from donor countries could lead to a further $21.2 ($16.6–25.6) billion in patient-incurred costs and 10.7 (8.4–13.0) million households experiencing catastrophic costs. If all external TB funding were terminated, a projected $72.2 ($53.9–90.4) billion in patient-incurred costs could accrue and 36.6 (27.7–46.1) million households could experience catastrophic costs, compared with the impact of the funding cuts to USAID alone.
Implications of all the available evidence
Disruptions to TB services resulting from reductions in international donor funding could result in increased tuberculosis-associated morbidity and mortality, which in turn could result in increased economic burden on resource-constrained households in the world’s poorest countries. Strategies to reduce the disruption caused by funding cuts and protect vulnerable populations are urgently needed.
