Converting donor dependence to domestic ownership: The realignment of tuberculosis financing for sustainability

The financing of tuberculosis (TB) programs in high burden countries (HBCs) requires an overhaul. Donor funding for TB has often bypassed domestic channels, decreased the incentive for engagement between national TB programs and national budget holders, and provided minimal assistance to improve domestic TB budgeting processes. The result is local budgeting and financial management processes that do not efficiently and effectively meet both curative and public health TB needs. Meanwhile, donor TB funding has become less certain. Our analysis suggests that, in almost three quarters of high TB burden countries, increases in health budgets and in the proportion of health budgets dedicated to TB could compensate financially for a complete withdrawal of donor funding for TB. However, marginalized populations may be left behind and, in countries with less resources, major gaps will remain. Ministries of Health and Finance should assess whether the country can pay for more of its own TB response; this includes defining TB-specific financing needs, and assigning these needs to specific domestic financing sources. They should also demand that future TB donor funds flow through domestic channels, and prioritise TB in their engagement with Multilateral Development Banks (MDBs). Donors and MDBs should: renew their commitment to funding TB; ensure that TB donor funds and TB loans flow through domestic systems; communicate more clearly around transition; provide assistance related to advocacy, accountability, and the raising, allocation and more efficient use of domestic TB funding; and target TB implementation funding to lower-income countries where it is most urgently needed. The end result would be national TB programs that are system-aligned, with donor support that is more clearly differentiated between implementation and system building in lower-income countries and addressing health system constraints in middle-income countries.