{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T18:05:56Z","timestamp":1780077956593,"version":"3.54.0"},"reference-count":105,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T00:00:00Z","timestamp":1780012800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Gates Foundation","award":["INV-093982"],"award-info":[{"award-number":["INV-093982"]}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.1371\/journal.pgph.0006523","type":"journal-article","created":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T17:38:26Z","timestamp":1780076306000},"page":"e0006523","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Converting donor dependence to domestic ownership: The realignment of tuberculosis financing for sustainability"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4360-1263","authenticated-orcid":true,"given":"William A.","family":"Wells","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Scheening","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-8746-7890","authenticated-orcid":true,"given":"Saba","family":"Waseem","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amanda","family":"Schulhofer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-8009-0274","authenticated-orcid":true,"given":"Yemelaknesh","family":"Wolde","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guy","family":"Stallworthy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,5,29]]},"reference":[{"key":"pgph.0006523.ref001","author":"JL Ravelo","year":"2025"},{"key":"pgph.0006523.ref002","article-title":"After USAID: what now for aid and Africa?","volume":"388","author":"C Kyobutungi","year":"2025","journal-title":"BMJ"},{"key":"pgph.0006523.ref003","author":"JL Ravelo","year":"2025"},{"issue":"4","key":"pgph.0006523.ref004","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0004440","article-title":"A Critical juncture in global health: Leveraging historical institutionalism to examine PEPFAR dependency and inform the development of self-reliant public health systems","volume":"5","author":"A Wiyeh","year":"2025","journal-title":"PLOS Glob Public Health"},{"key":"pgph.0006523.ref005","author":"Center for Healthy Development","year":"2025"},{"issue":"349","key":"pgph.0006523.ref006","doi-asserted-by":"crossref","first-page":"01","DOI":"10.1111\/j.2040-0209.2010.00349_2.x","article-title":"Global Poverty and the New Bottom Billion: What if Three\u2010quarters of the World\u2019s Poor Live in Middle\u2010income Countries?","volume":"2010","author":"A Sumner","year":"2010","journal-title":"IDS Working Papers"},{"key":"pgph.0006523.ref007","author":"V Fan","year":"2024"},{"key":"pgph.0006523.ref008","volume-title":"Health financing reforms in support of universal health coverage: A case study for Rwanda","author":"SY Oketch","year":"2024"},{"key":"pgph.0006523.ref009","volume-title":"Financing tuberculosis: context; economic case; and political considerations","author":"Health Systems for TB","year":"2022"},{"issue":"9","key":"pgph.0006523.ref010","doi-asserted-by":"crossref","first-page":"375","DOI":"10.5588\/ijtldopen.24.0324","article-title":"The intersection of TB and health financing: defining needs and opportunities","volume":"1","author":"WA Wells","year":"2024","journal-title":"IJTLD Open"},{"key":"pgph.0006523.ref011","volume-title":"Global TB report. International donor funding for tuberculosis: an analysis of donor reports to the Organisation for Economic Co-operation and Development","author":"WHO","year":"2025"},{"key":"pgph.0006523.ref012","volume-title":"Towards a proposal for a novel TB vaccine R&D financing initiative","author":"IAVI","year":"2025"},{"key":"pgph.0006523.ref013","author":"JL Ravelo","year":"2025"},{"key":"pgph.0006523.ref014","volume-title":"Responding to the health financing emergency: Immediate measures and longer-term shifts","author":"WHO","year":"2025"},{"key":"pgph.0006523.ref015","volume-title":"Sustainable Solutions to the Global Health Financing Crisis","author":"Center for Global Development","year":"2025"},{"key":"pgph.0006523.ref016","author":"JL Ravelo","year":"2025"},{"key":"pgph.0006523.ref017","author":"JL Ravelo","year":"2025"},{"key":"pgph.0006523.ref018","author":"NA Evaborhene","year":"2025"},{"key":"pgph.0006523.ref019","volume-title":"U.S. Quietly Drafts Plan to End Program That Saved Millions From AIDS","author":"S Nolen","year":"2025"},{"key":"pgph.0006523.ref020","author":"J Sandefur","year":"2025"},{"key":"pgph.0006523.ref021","volume-title":"Stop TB cuts over a quarter of staff amid shift in US priorities","author":"JL Ravelo","year":"2025"},{"key":"pgph.0006523.ref022","author":"A Green","year":"2025"},{"key":"pgph.0006523.ref023","volume-title":"The impact of suspensions and reductions in health official development assistance on health systems: rapid WHO country office stock take","author":"WHO","year":"2025"},{"issue":"5","key":"pgph.0006523.ref024","doi-asserted-by":"crossref","first-page":"239","DOI":"10.5588\/ijtld.24.0215","article-title":"Impact of US Government funding cessation on TB care and prevention: a multicountry survey in Africa","volume":"29","author":"KG Koura","year":"2025","journal-title":"Int J Tuberc Lung Dis"},{"issue":"4","key":"pgph.0006523.ref025","doi-asserted-by":"crossref","first-page":"241","DOI":"10.5588\/ijtldopen.25.0168","article-title":"Impact of US funding cuts and stop work orders on TB services and research in South Africa","volume":"2","author":"N Ndjeka","year":"2025","journal-title":"IJTLD Open"},{"key":"pgph.0006523.ref026","author":"PI Ihejirikia","year":"2025"},{"issue":"9","key":"pgph.0006523.ref027","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0004899","article-title":"A Deadly Equation: The Global Toll of US TB Funding Cuts.","volume":"5","author":"S Mandal","year":"2025","journal-title":"PLOS Glob Public Health"},{"issue":"11","key":"pgph.0006523.ref028","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1016\/S2352-4642(25)00218-4","article-title":"Potential paediatric tuberculosis incidence and deaths resulting from interruption in programmes supported by international health aid, 2025-34: a mathematical modelling study","volume":"9","author":"NA Menzies","year":"2025","journal-title":"Lancet Child Adolesc Health"},{"issue":"9","key":"pgph.0006523.ref029","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(25)00232-3","article-title":"The potential impact of reductions in international donor funding on tuberculosis in low-income and middle-income countries: a modelling study","volume":"13","author":"RA Clark","year":"2025","journal-title":"Lancet Glob Health"},{"key":"pgph.0006523.ref030","author":"WHO","year":"2021"},{"key":"pgph.0006523.ref031","author":"WA Wells","year":"2025","journal-title":"Data for converting donor dependence to domestic ownership: The realignment of tuberculosis financing for sustainability"},{"key":"pgph.0006523.ref032","author":"World Health Organization WHO"},{"key":"pgph.0006523.ref033","author":"World Health Organization WHO"},{"key":"pgph.0006523.ref034","author":"World Bank Group"},{"key":"pgph.0006523.ref035","author":"World Bank Group"},{"key":"pgph.0006523.ref036","author":"IBAN"},{"issue":"23","key":"pgph.0006523.ref037","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1098\/rsif.2007.1138","article-title":"Eliminating human tuberculosis in the twenty-first century","volume":"5","author":"C Dye","year":"2008","journal-title":"J R Soc Interface"},{"key":"pgph.0006523.ref038","author":"J Chase-Lubitz","year":"2025"},{"key":"pgph.0006523.ref039","doi-asserted-by":"crossref","first-page":"100599","DOI":"10.1016\/j.ijregi.2025.100599","article-title":"Lessons and updates from India\u2019s National Tuberculosis Elimination Program - bold decisions and innovative ways of fast-tracking progress toward ending tuberculosis","volume":"14","author":"UB Singh","year":"2025","journal-title":"IJID Reg"},{"key":"pgph.0006523.ref040","author":"International Monetary Fund IMF"},{"key":"pgph.0006523.ref041","author":"RF Junquera-Varela","year":"2018"},{"key":"pgph.0006523.ref042","volume-title":"Abuja declaration on HIV and AIDS, tuberculosis and other related infectious diseases","author":"African Union","year":"2001"},{"key":"pgph.0006523.ref043","volume-title":"From overall fiscal space to budgetary space for health: Connecting public financial management to resource mobilization in the era of COVID-19","author":"H Barroy","year":"2020"},{"issue":"6","key":"pgph.0006523.ref044","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002837","article-title":"Middle-income countries graduating from health aid: transforming daunting challenges into smooth transitions","volume":"16","author":"G Yamey","year":"2019","journal-title":"PLoS Med"},{"issue":"11","key":"pgph.0006523.ref045","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1004794","article-title":"How can middle-income countries successfully transition away from international health aid?","volume":"22","author":"O Ogbuoji","year":"2025","journal-title":"PLoS Med"},{"key":"pgph.0006523.ref046","volume-title":"Integrating TB into national health financing systems: A report on implementing the TB financial sustainability index in 10 high TB burden countries","author":"S Scheening","year":"2025"},{"key":"pgph.0006523.ref047","author":"International Union Against Tuberculosis and Lung Disease","year":"2017"},{"key":"pgph.0006523.ref048","author":"Stop TB Partnership","year":"2018"},{"issue":"10157","key":"pgph.0006523.ref049","doi-asserted-by":"crossref","first-page":"1513","DOI":"10.1016\/S0140-6736(18)32541-8","article-title":"From silos to sustainability: transition through a UHC lens","volume":"392","author":"J Kutzin","year":"2018","journal-title":"Lancet"},{"key":"pgph.0006523.ref050","volume-title":"Tuberculosis and primary health care: synergies and opportunities towards universal health coverage","author":"WHO","year":"2025"},{"key":"pgph.0006523.ref051","author":"S Sparkes"},{"issue":"2","key":"pgph.0006523.ref052","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1093\/heapol\/czp055","article-title":"Integration of targeted health interventions into health systems: a conceptual framework for analysis","volume":"25","author":"R Atun","year":"2010","journal-title":"Health Policy Plan"},{"key":"pgph.0006523.ref053","volume-title":"WHO operational handbook on tuberculosis: module 2: screening: systematic screening for tuberculosis disease","author":"WHO","year":"2022"},{"issue":"8","key":"pgph.0006523.ref054","first-page":"663","article-title":"Tuberculosis prevention and control activities in the United States: an overview of the organization of tuberculosis services","volume":"3","author":"NJ Binkin","year":"1999","journal-title":"Int J Tuberc Lung Dis"},{"key":"pgph.0006523.ref055","year":"2025"},{"key":"pgph.0006523.ref056","volume-title":"Tuberculosis Financial Sustainability Index (TB FSI): Implementation Guide","year":"2025"},{"key":"pgph.0006523.ref057","author":"S Scheening","year":"2025"},{"key":"pgph.0006523.ref058","author":"T Drake","year":"2023"},{"key":"pgph.0006523.ref059","volume-title":"Making the Case for Health: A Messaging Guide for Domestic Resource Mobilization","author":"A Tandon","year":"2021"},{"key":"pgph.0006523.ref060","article-title":"More money for health","volume-title":"The world health report: health systems financing: the path to universal coverage","author":"WHO","year":"2010"},{"key":"pgph.0006523.ref061","volume-title":"Kenya TB Financing Roadmap FY2023\/24-FY2027\/28","author":"Ministry of Health K","year":"2024"},{"key":"pgph.0006523.ref062","doi-asserted-by":"crossref","first-page":"100599","DOI":"10.1016\/j.ijregi.2025.100599","article-title":"Lessons and updates from India\u2019s National Tuberculosis Elimination Program - bold decisions and innovative ways of fast-tracking progress toward ending tuberculosis","volume":"14","author":"UB Singh","year":"2025","journal-title":"IJID Reg"},{"key":"pgph.0006523.ref063","article-title":"Uganda increases health sector budget to Shs 5.87 Tn in FY 2025\/26","author":"H Mugenyi","year":"2025","journal-title":"NilePost"},{"key":"pgph.0006523.ref064","volume-title":"A balancing act: Health financing in devolved settings","author":"ThinkWell, World Health Organization","year":"2022"},{"key":"pgph.0006523.ref065","volume-title":"Assessment of Ethiopia\u2019s health sector co-financing framework","author":"Health Systems for TB","year":"2024"},{"key":"pgph.0006523.ref066","volume-title":"Strengthening the sustainability of Kenya\u2019s tuberculosis response: An assessment of county-level engagement in planning and budgeting processes","year":"2023"},{"key":"pgph.0006523.ref067","first-page":"918188","article-title":"Successes and obstacles in implementing social health insurance in developing and middle-income countries: A scoping review of 5-year recent literatures","volume":"10","author":"MH Jamal","year":"2023","journal-title":"Journal Title"},{"issue":"12","key":"pgph.0006523.ref068","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2024-085903","article-title":"Social Health Insurance for Universal Health Coverage in Low and Middle-Income Countries (LMICs): a retrospective policy analysis of attainments, setbacks and equity implications of Kenya\u2019s social health insurance model","volume":"14","author":"S Nungo","year":"2024","journal-title":"BMJ Open"},{"issue":"1","key":"pgph.0006523.ref069","doi-asserted-by":"crossref","first-page":"26","DOI":"10.5588\/ijtld.18.0289","article-title":"How tuberculosis programs can navigate the world of social health insurance","volume":"23","author":"WA Wells","year":"2019","journal-title":"Int J Tuberc Lung Dis"},{"key":"pgph.0006523.ref070","author":"WHO","year":"2025"},{"key":"pgph.0006523.ref071","volume-title":"The Case for Health Taxes","author":"M Ahmed","year":"2025"},{"issue":"4","key":"pgph.0006523.ref072","doi-asserted-by":"crossref","first-page":"555","DOI":"10.1016\/j.ijtb.2019.11.009","article-title":"Fuelling the tuberculosis epidemic: The role of tobacco control in ending the TB emergency","volume":"66","author":"S Goel","year":"2019","journal-title":"Indian J Tuberc"},{"issue":"9","key":"pgph.0006523.ref073","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2025-019770","article-title":"Taxes for tuberculosis: could tobacco and sugar tax revenue fund tuberculosis control interventions?","volume":"10","author":"M Coleman","year":"2025","journal-title":"BMJ Glob Health"},{"key":"pgph.0006523.ref074","article-title":"Tanzania injects Sh298bn to offset donor health cuts","author":"R Mirondo","year":"2025","journal-title":"The Citizen"},{"issue":"2","key":"pgph.0006523.ref075","first-page":"763","article-title":"Sin taxes: Have governments gone too far in their efforts to monetize morality?","volume":"59","author":"F Liu","year":"2018","journal-title":"Boston College Law Review"},{"key":"pgph.0006523.ref076","article-title":"Which sins should we tax?","author":"NA Sarfo","year":"2023","journal-title":"Forbes"},{"key":"pgph.0006523.ref077","volume-title":"Earmarking for health: from theory to practice","author":"World Health Organization","year":"2017"},{"key":"pgph.0006523.ref078","author":"Global Fund"},{"key":"pgph.0006523.ref079","volume-title":"Restructuring paper on a proposed program restructuring of Program Towards Elimination of Tuberculosis approved on March 29, 2019 to the Republic of India","author":"World Bank","year":"2024"},{"key":"pgph.0006523.ref080","author":"World Bank"},{"key":"pgph.0006523.ref081","author":"World Bank","year":"2020"},{"key":"pgph.0006523.ref082","author":"UN Trade and Development U","year":"2025"},{"key":"pgph.0006523.ref083","author":"I Gill","year":"2025"},{"key":"pgph.0006523.ref084","doi-asserted-by":"crossref","DOI":"10.1596\/43745","volume-title":"At a Crossroads: Prospects for Government Health Financing Amidst Declining Aid","author":"A Kumar","year":"2025"},{"key":"pgph.0006523.ref085","author":"H Koster","year":"2025"},{"key":"pgph.0006523.ref086","author":"Asian Venture Philanthropy Network","year":"2024"},{"key":"pgph.0006523.ref087","author":"S Ogundipe","year":"2024"},{"key":"pgph.0006523.ref088","doi-asserted-by":"crossref","DOI":"10.1787\/e4a13d2c-en","volume-title":"OECD DAC Blended Finance Guidance 2025","author":"OECD","year":"2025"},{"key":"pgph.0006523.ref089","volume-title":"National surveys of costs faced by TB patients and their households, 2015\u20132021","author":"WHO","year":"2022"},{"key":"pgph.0006523.ref090","article-title":"A Critical Reflection on Social Impact Bonds","author":"N McHugh","year":"2018","journal-title":"Stanford Social Innovation Review"},{"key":"pgph.0006523.ref091","volume-title":"Lessons from the Global Fund\u2019s successful implementation of debt swaps \u2013 The Debt2Health","author":"Global Fund"},{"key":"pgph.0006523.ref092","author":"UHC2030"},{"key":"pgph.0006523.ref093","author":"Global Fund","year":"2024"},{"key":"pgph.0006523.ref094","volume-title":"Debt for what swaps? Guiding principles for the allocation of debt swap resources","author":"A Ababou","year":"2025"},{"key":"pgph.0006523.ref095","volume-title":"The World Bank Booster Program for Malaria Control in Africa: Scaling-Up for Impact (SUFI). A Two-Year Progress Report","author":"World Bank","year":"2007"},{"key":"pgph.0006523.ref096","author":"DG Boko","year":"2025"},{"key":"pgph.0006523.ref097","volume-title":"Towards universal health coverage: thinking public. Overview of trends in public expenditure on health (2000-2014)","author":"H Barroy","year":"2017"},{"key":"pgph.0006523.ref098","volume-title":"How to make budgets work for health? A practical guide to designing, managing and monitoring programme budgets in the health sector","author":"H Barroy","year":"2022"},{"key":"pgph.0006523.ref099","volume-title":"Making the Case for Health: A Messaging Guide for Domestic Resource Mobilization","author":"A Tandon","year":"2021"},{"key":"pgph.0006523.ref100","author":"T Drake","year":"2023"},{"key":"pgph.0006523.ref101","author":"J Kates"},{"key":"pgph.0006523.ref102","author":"Global Fund","year":"2013","journal-title":"Update on co-financing"},{"key":"pgph.0006523.ref103","article-title":"Government to Government (G2G) Model for HIV Service Delivery \u2013 An Approach for Program Ownership and Sustainability in Four Provinces of Zambia","author":"K Mweebo","year":"2025","journal-title":"medRxiv"},{"key":"pgph.0006523.ref104","author":"K Chalkidou","year":"2024"},{"key":"pgph.0006523.ref105","author":"V Fan","year":"2024"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006523","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T17:38:38Z","timestamp":1780076318000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006523"}},"subtitle":[],"editor":[{"given":"Paulo Jorge Gon\u00e7alves de","family":"Bettencourt","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,5,29]]},"references-count":105,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5,29]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0006523","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,29]]}}}