who decides? inequity of global financing for TB

By Sahera Ramzan and Vinny Wooding

What is the Global Fund and what does it do?

Established in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria has invested over US $65 billion in 155 countries saving 59 million lives. The Global Fund is a financing mechanism to improve health outcomes and end the HIV, tuberculosis (TB), and malaria epidemics. It is the world’s largest funder of global health grants in low and middle-income countries. This is achieved through raising and investing funds in three-year cycles known as replenishments, where partners in national governments and the private sector commit new funding. The replenishment cycle aims to provide stable funding to the countries that receive Global Fund grants and ensure programmes for HIV, TB and malaria can continue to operate. 

Inequitable funding allocation

Since 2013, the Global Fund has allocated 50% of its resources to HIV, 32% to malaria, and 18% to TB. The percentage allocated to TB does not match the level of disease burden. In 2022, globally there were 1.3 million deaths from TB, compared to 630,000 for HIV and 608,000 for malaria. In 2022, global funding available for TB was approximately $7.9 billion, compared with $20 billion for HIV. Further, TB is much more exposed to drug-resistance than either HIV or malaria. It is clear that TB is being marginalised in global health. The sheer scale of global TB deaths cannot be ignored. Since TB is an airborne infectious disease, it has the potential to develop to pandemic proportions. How can this deadly disease receive the least amount of funding? The Global Fund, as the largest annual funder of TB programming, must take some responsibility for that. 

There is a strong case to be made for allocating more resources to TB. Between 2009 and 2022 there has been a continuous increase in deaths related to TB. In 2009, TB had the highest share of deaths (40%) compared to HIV (39%) and malaria (20%). In 2022 this share had increased to 47% for TB and 26% for malaria; while the share for HIV had significantly decreased to 27%. An independent evaluation was commissioned to analyse the current methodology of allocating funds across the three diseases. The evaluation recommended that the allocation for TB should be increased, given the high disease burden. Yet little has come in response to the evaluation, and TB is still being under-prioritised. In advance of the Global Fund’s 7th Replenishment in 2022, the Global Fund indicated that TB funding would be uplifted should it meet their $18 billion funding target. This target was never reached; thus TB remained relatively poorly funded. 

New challenges have emerged for TB with an increase in drug resistance. The growing burden of drug-resistant TB is a major contributor to antimicrobial resistance – when diseases become resistant to the drugs that are meant to treat them. In 2022, there were an estimated 410,000 cases of drug-resistant TB, which contributes significantly to global antimicrobial resistance. One-third of all deaths from antimicrobial-resistant infections are due to drug-resistant TB, posing a threat to global public health.

The Global Fund is the main funder for global TB, providing 76% of all global financing. This is not the case for HIV, which has other funding streams such as UNAIDS and PEPFAR. The Global Fund only accounts for 28% of all global financing for HIV and 65% for malaria. TB has never had the full level of funding required to address prevention, diagnosis, and treatment. This has been acknowledged in the TB political declaration agreed by member states at the United Nations General Assembly in 2023. The new declaration states that a higher level of global funding is needed for TB prevention, diagnosis, and treatment (US $22 billion annually).

The current Global Fund strategy: Fighting pandemics and building a healthier and more equitable world, clearly outlines the need to focus on equity (amongst other areas) to enhance its impact. Equity in global health means that everyone, regardless of geographical location, socio-economic status, race, gender, or other factors, should have fair and just access to the highest standards of healthcare and the resources to maintain good health. 

The funding allocation for the three diseases is far from equitable. TB advocates across the globe have been sounding the alarm on the marginalisation of TB for decades. Yet each time, those calls have gone unheard – whether by national governments, multilateral organisations, or the private sector. TB has never benefited from the high-profile media and celebrity campaigns that catapulted HIV and malaria into the West’s national consciousness, helping to reduce the disease burden and associated stigma. As such, TB continues to be relegated, in both financial and political terms, to the third and last of these three diseases. TB is furthest back in the race for eradication, and the finish line keeps moving. 

It is time for TB to get the international attention necessary for eradication. That starts with the largest funder of TB programmes annually: The Global Fund. Why should the international community increase the prioritisation of TB when even the Global Fund doesn’t give it an equitable slice of its funding? As the largest actor in TB eradication, the Global Fund has a responsibility to lead the charge for equitable funding. It could use this power and influence to encourage national governments, other multilaterals, and the private sector to do their part to end the TB epidemic. 

It is time to end this injustice. Join the TB community in signing a petition to demand that the Global Fund fix its discriminatory disease split.