Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000–17: a financial modelling study

Background Estimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000-17.Methods We extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$.Findings Total spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3.9% (95% CI 3.0 to 4.6), from $5.7 billion (5.2 to 6.5) in 2000 to $10.9 billion (10.3 to 11.8) in 2017. Government spending increased annually by 5.1% (4.4 to 5.7) between 2000 and 2017, and reached $6.9 billion (6.5 to 7.5) or 63.5% (59.2 to 66.8) of all tuberculosis spending in 2017. Of government spending, $5.8 billion (5.6 to 6.1) was spent on notified cases. Out-of-pocket spending decreased annually by 0.8% (-2.9 to 1.3), from $2.4 billion (1.9 to 3.1) in 2000 to $2.1 billion (1.6 to 2.7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54.6 million in 2000 to $1.1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85.3 million in 2000 to $576.2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73.7% (71.8-75.8) of tuberculosis spending in 2017.Interpretation Despite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending.