Tuberculosis proves that investment in health pays off

For a disease that has plagued humankind for centuries, tuberculosis (TB) continues to be a devastating problem in low- and middle-income countries. An estimated global total of 10.7 million people fell ill with TB in 2024, and 1.23 million people died of TB the same year, making TB the single biggest infectious killer of people worldwide.¹ And things are expected to get worse because of all the ongoing cuts in development assistance by G7 nations.²

Even today, social determinants are the biggest drivers of the TB epidemic, especially poverty, undernutrition, inadequate housing and lack of healthcare and social protection.³

Beyond morbidity and deaths, TB exacts a massive toll on society. TB kills mostly young adults and thus drains nations of their most productive workforce. In addition, households with people impacted by TB often incur catastrophic costs related to TB management.⁴ For example, in a multi-state study on India, about 30%-61% of patients living with TB faced catastrophic costs.⁵

Because TB is a contagious threat that has a major social impact, investing in TB offers an exceptional return on investment. Cost-benefit analyses of increased spending on tuberculosis indicate that the return on spending is substantial—every US$1 invested in TB yields $46 in benefits.⁶

But we know from history that TB can be controlled. In most high-income countries, TB rates have dramatically declined over the past century, in part because of improved socioeconomic conditions, and because of access to quality TB care.⁷ Today, we have excellent rapid molecular diagnostics, preventive therapies, and can even cure drug-resistant disease with shorter treatments. We also have strong evidence that nutrition and other forms of social support can save lives and prevent TB.³

The real need, therefore, is for high-TB-burden countries to invest more in TB care and social protection, even as international aid shrinks. In a recent essay, health ministers of four of the world’s highest-burden TB countries, accounting for 25% of the global TB cases, wrote: “To keep our citizens healthy and productive, we must pivot to increases in domestic funding and innovative, domestically anchored financing models that are resilient, equitable, efficient and scalable.”⁸ They recommended a range of approaches, including raising taxes on tobacco and alcohol, working with development banks for results-based financing, swapping debt for health, and leveraging private-sector resources.⁸

Some countries (e.g. China, India, Brazil, South Africa and Indonesia) have made big investments in TB and health services, and the results are starting to show. For example, China has achieved remarkable progress in poverty alleviation (which has a strong correlation with TB) and comprehensive TB care, meeting its goal of a 20% reduction in TB incidence from 2015 to 2024. India has tripled its domestic budget for TB, and has disbursed approximately $535m from domestic funding via its cash-transfer programme for people with TB.⁹ Greater investments by high-burden countries make them less reliant on development assistance and more likely to have a sustainable TB response.

Indonesia is investing heavily in transforming its health system, aiming for 3.5% of GDP spending, with a $4bn Health Systems Strengthening Project and a focus on expanding universal health coverage.¹⁰ Chinese and Indian manufactured diagnostics are poised to offer affordable and highly scalable options for high-burden countries.¹¹ And South Africa has been a leader in the adoption of new TB and HIV tools, including rapid molecular testing¹², shorter, all-oral drug treatments for drug-resistant TB¹³, and lenacapavir for preventing HIV¹⁴, which is the most powerful risk factor for TB in sub-Saharan Africa.

Given the massive decline in foreign aid and the challenging geopolitical landscape today, it is critical that global-south countries take on a leadership role for ending TB, a disease that impacts them the most. These nations have lived experience with TB, deep expertise in care delivery, ability to innovate and manufacture tools, and incredible potential to scale best practices that can bend the curve of this persistent plague.

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