Urgent need for increased investments to end tuberculosis in the South-East Asia region

Tuberculosis (TB) has been a major contributor to deaths due to communicable diseases among the productive population in the World Health Organization (WHO) South-East Asia (SEA) region for more than a decade¹. Of the ~10.8 million people in 2021who developed TB globally, more than 45 per cent were from the 11 countries (Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste) of the SEA region². More than half of all the global deaths due to TB were from the SEA region which also shares around 37 per cent of the burden of multidrug-resistant/rifampicin-resistant TB globally. As the world strives to end TB by 2030, the progress achieved in the SEA region will be the determinant of the global epidemiological TB trajectory in the coming years.

While the countries of this region have intensified their efforts towards ending TB in recent years, the COVID-19 pandemic has reversed progress because of reduced access to health services, leading to decreased notification of TB patients and aggravation of TB determinants such as undernourishment and poverty². Restrictions related to the COVID-19 pandemic have had a direct impact – as visible in the underdetection of TB cases of all forms, reduced coverage of TB preventive treatment and disruption in ongoing treatment. Major shortfalls in TB case notifications have been reported in the SEA region for both 2020 and 2021. In 2020, 2.6 million people with a new or relapse episode of TB were notified, down 24 per cent from those in 2019, larger than the overall global shortfall of 18 per cent³. In 2021, there has been a partial recovery, to three million, but this is still 12 per cent less than in 2019. An additional seven million people are likely to develop TB and 1.5 million more will die due to TB over the next five years in this region because of COVID-19-related disruptions, unless urgent action is taken to cover the lost ground due to the COVID-19 pandemic⁴. Loss of wages specifically for daily wage earners due to lockdowns during the COVID-19 pandemic meant that higher proportion of earnings were spent on direct and indirect costs of treatment and hence, higher proportions of catastrophic costs and undernutrition. Poverty and undernutrition have been linked to higher TB incidence, and hence, the aggravation is likely to lead to higher TB incidence².

Therefore, investments in comprehensive strategies that do not merely address biomedical aspects of the disease but also the social determinants are required, more than ever to bring the progress towards ending TB back on track.

Globally, ending TB has received the highest possible attention in recent times. The United Nations (UN) high level meeting (HLM) on TB held in September 2018 came up with a political declaration that laid global coverage targets to accelerate the progress towards ending TB with a required annual investment of US$ 13 billion annually from 2022 onwards to make substantive progress⁵. This was during the pre-COVID-19 period. It is anticipated that countries will need urgent investments of larger scale because of setbacks to TB programmes during this period.

The political will for ending TB in the SEA region has been expressed on several platforms – the regional ministerial meeting in 2017, end-TB summit in 2018 and a virtual HLM for renewed efforts towards ending TB, in 2021. During the virtual HLM in 2021, a “Regional Strategic Plan towards ending TB in the WHO South-East Asia region, 2021-2025”, was released⁶, which makes a case for increase in funding availability for TB programmes in the Region reaching US$ 3 billion to implement priority, people-centred and multi-sectoral approaches. The priority interventions not only include a biomedical approach but also offer social protection to all those affected by the disease. Once the peak investments and implementation levels are achieved, the annual needs for investments will start declining (Fig. 1). At country-level commitments from the highest political levels have been seen, notable among these being Prime Minister’s call to end TB by 2025 in India⁷, Presidential Decree in Indonesia⁸, TB Free Initiative in Nepal⁹ and Prime Minister led multipartner commitments in Timor-Leste¹⁰.

Fig. 1: TB programme funding requirements for the SE Asia region as compared with funding availability. Source: Refs 3, 6. TB, tuberculosis

These commitments have had some positive impact on the national TB programmes (NTPs). The annual budget of NTPs from the SEA region saw a significant increase from US$ 578 million in 2015 to US$ 1389 million in 2022³. The domestic funding also more than tripled, from US$ 168 to 539 million during the same period. However, the actual funding received by national programmes has been around US$ 700 million for several years, with a peak of US$ 745 million in 2018, but gradually decreasing to US$ 635 million in 2021 - just over 1/5^th of the actual needs. Because of the possible diversion of resources during the COVID-19 period, the gap between the national budgets and actual funding received increased to US$ 791 million in 2021 (Fig. 2). This clearly shows that TB programmes in the region are grossly underfunded even against the planned budgets.

Fig. 2: Trends in budgets for TB programmes, total funding received and total expenditures in the SE Asia region (2017-2022). Source: Ref 3.

Continued funding shortfalls will result in gaps in service coverage, lesser outreach and hence preventable deaths. The continuous spread of the disease will also result in little decline in TB incidence, and hence, even larger long-term resource requirements to meet the targets of ending TB.

Among communicable diseases, investments in Ending TB is one of the most cost-effective interventions. A TB patient who gets cured by an effective treatment in productive years has an extension of an additional 20 years compared to a person with TB who gets no treatment. According to the Copenhagen Consensus statement, “every dollar invested in averting TB deaths returns on an average US$ 43 dollars in economic benefits”¹¹. The analysis conducted also shows that achieving the targets enshrined in the WHO End TB Strategy by 2035 would have a “benefit-to-cost ratio between 16 and 82” making a most positive impact for the poorest.

Increased investment in the SEA Region can avert nearly 4.5 million new cases of TB and one million deaths between 2022-2025. These investments may also prevent the loss of over 31 million disability-adjusted life years (DALYs) which in turn would contribute towards the socioeconomic development of the member States⁶. Delays in investments would mean that these gains will not be realized.

Some of these costs may need to be frontloaded for prioritizing interventions such as intensified case finding, outreach activities aimed at household contact screening and TB preventive treatment, increased coverage of social protection for all TB patients but specifically the vulnerable groups and introduction of new tools and technologies. These interventions need to be complemented with community engagement in monitoring, governance, law and policy reform, in addition to service delivery. Countries also need to be prepared for investments in adoption and rollout of vaccines for TB as and when these are available in near future.

Overall, the current funding levels will need to be trebled. There is also a need for introducing efficiencies through integrated, primary healthcare approaches that address determinants. As a long-term intervention, there is a need to mainstream social protection measures, another learning from the COVID-19 pandemic. Digital technologies including the use of social media could reduce the costs of patient outreach and programme management. Simultaneously, the capacity of national programmes to improve the absorptive capacity of available funds and undertake ambitious planning needs to be improved.

However, the current funding mechanisms may not be sufficient and domestic budgets may see competing priorities. Innovative financing through multisectoral engagement including the private sector, primary healthcare approach including community empowerment and use of new technologies could help achieve the investment targets and restore progress towards ending TB. The upcoming UNHLM for TB in September 2023 provides an opportunity for countries and all stakeholders, globally and in the SEA region to renew their commitments towards ending TB, set ambitious targets, establish platforms for multi-sectoral coordination and ensure that enough resources are available in the coming years to realistically achieve the vision of a world free of TB.

Financial support & sponsorship: None.

Conflicts of Interest: The work represents the personal opinion of the authors and may not necessarily represent that of the organization for which they work.

Content reproduced/adapted from references 3 and 6 are in compliance with WHO’s policy on the non-commercial reuse of the data published by the WHO.