Monitoring Universal Health Coverage (UHC) in high Tuberculosis burden countries: Tuberculosis mortality an important tracer of UHC service coverage

Background: There is a paucity of empiric data evaluating whether Tuberculosis (TB) is a useful surrogate measure for Universal Health Coverage (UHC), despite recognition of the importance of TB control efforts as part of the broader UHC agenda. We hypothesized that indicators of TB burden and coverage are sensitive tracers of UHC, when compared to other disease-specific indicators of service provision. Methods: Linear regression models were used to determine the extent to which variability in UHC Service Coverage Index (SCI) was accounted for by (1) TB incidence rates and (2) TB mortality rates across 183 countries. Dominance analyses, stratifying countries by World Bank income criteria and TB burden, were used to determine the importance of TB treatment coverage in predicting UHC SCI scores, relative to other disease-specific indicators of service provision. Results: Across 183 countries, TB incidence rate and TB mortality rate were negatively correlated, with UHC SCI score, (r = -0.67 and r = -0.74, respectively). In linear regression models including all 183 countries, TB incidence rates explained 45% of the variability in SCI scores; TB mortality rate explained 55% of variability. Restricting models to the 30 highest TB burden countries, both incidence and mortality explained less of the variability in SCI score (16% and 36%, respectively). In dominance analysis, comparing 13 disease-specific indicators of service provision, TB effective treatment coverage, ranked ninth overall. In dominance analysis stratified by TB burden, the TB treatment coverage estimate was ranked ninth in the 30 high burden countries and sixth in the 153 non-high burden countries. In separate analyses stratified by world bank income status, TB coverage ranked as third most important variable in LICs and fifth in LMICs and UMICs, but was less important in analysis restricted HICs (ranked seventh). Conclusions: Compared to other disease-specific indicators of service provision, TB coverage was an important indicator of overall UHC service coverage, especially in low-income countries. These findings highlight that national-level inequities in TB-coverage may be an important tracer of universal health coverage.