{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T19:20:56Z","timestamp":1772220056934,"version":"3.50.1"},"update-to":[{"DOI":"10.1371\/journal.pmed.1004946","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T00:00:00Z","timestamp":1772150400000}}],"reference-count":24,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T00:00:00Z","timestamp":1771545600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Recent shifts in the global health funding landscape\u2014most notably the dismantling of the United States Agency for International Development (USAID) and possible reduced contributions to the Global Fund to Fight AIDS, TB, and Malaria (Global Fund)\u2014threaten essential tuberculosis (TB) services in low- and middle-income countries (LMICs). We quantified the potential impact on the household economic burden of TB.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods and findings<\/jats:title>\n                    <jats:p>We used linked epidemiological and economic models, calibrated to 79 LMICs, to estimate future TB patient costs under six scenarios: continuation of 2024 funding levels (baseline), termination of USAID, termination of USAID plus announced reductions in Global Fund contributions from the USA alone, termination of USAID plus complete termination of Global Fund contributions from the USA alone, termination of USAID plus announced reductions in Global Fund contributions from all donor countries contributing 1% or more to the budget, and full elimination of external funding for TB. Outcomes included total TB-attributable household costs and numbers of households experiencing catastrophic costs (disease-related costs &gt;20% of annual income). USAID termination was projected to produce US$7.5 (95% uncertainty interval: $6.1\u20138.9) billion in additional patient-incurred costs and 3.9 (3.1\u20134.6) million additional households experiencing catastrophic costs over 2025\u20132050. The worst-case scenario (elimination of all external funding) resulted in $79.7 ($60.0\u201399.2) billion in additional patient-incurred costs and 40.5 (30.9\u201350.7) million additional households experiencing catastrophic costs\u2014a 32% increase over baseline. Impacts were greatest for poorer households, with over 50% of additional catastrophic costs occurring in the poorest 20% of households. This analysis is limited by substantial uncertainty regarding costs faced by untreated patients and assumptions of constant patient costs and uniform treatment reductions over time.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Abrupt reductions in international donor funding for TB may reverse recent progress toward financial risk protection and health equity in LMICs. Strategies to reduce the disruption caused by funding cuts and protect vulnerable populations are urgently needed.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pmed.1004946","type":"journal-article","created":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T18:53:27Z","timestamp":1771613607000},"page":"e1004946","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["The potential impact of reduced international donor funding on the household economic burden of tuberculosis in low- and middle-income countries: A modeling study"],"prefix":"10.1371","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8467-1324","authenticated-orcid":true,"given":"Allison","family":"Portnoy","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8923-0301","authenticated-orcid":true,"given":"Rebecca A.","family":"Clark","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6658-8255","authenticated-orcid":true,"given":"Mark","family":"Jit","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6199-0931","authenticated-orcid":true,"given":"Christopher Finn","family":"McQuaid","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9886-8104","authenticated-orcid":true,"given":"Alexandra S.","family":"Richards","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roel","family":"Bakker","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9305-534X","authenticated-orcid":true,"given":"Tom","family":"Sumner","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6472-302X","authenticated-orcid":true,"given":"Tomos O.","family":"Pr\u0177s-Jones","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rein M. G. J.","family":"Houben","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4410-6635","authenticated-orcid":true,"given":"Richard G.","family":"White","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7542-4065","authenticated-orcid":true,"given":"Katherine C.","family":"Horton","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2571-016X","authenticated-orcid":true,"given":"Nicolas A.","family":"Menzies","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2026,2,20]]},"reference":[{"key":"pmed.1004946.ref001","volume-title":"Global tuberculosis report 2024","author":"World Health Organization","year":"2024"},{"issue":"12","key":"pmed.1004946.ref002","doi-asserted-by":"crossref","first-page":"294","DOI":"10.3390\/tropicalmed9120294","article-title":"The trend of tuberculosis case notification rates from 1995 to 2022 by country income and world health organization region","volume":"9","author":"KG Koura","year":"2024","journal-title":"Trop Med Infect Dis"},{"issue":"10","key":"pmed.1004946.ref003","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(23)00369-8","article-title":"Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysis","volume":"11","author":"A Portnoy","year":"2023","journal-title":"Lancet Glob Health"},{"key":"pmed.1004946.ref004","unstructured":"World Health Organization. The end TB strategy. 16 Aug 2015 [Online]. [cited 1 July 2021]. Available from: https:\/\/www.who.int\/teams\/global-tuberculosis-programme\/the-end-tb-strategy"},{"key":"pmed.1004946.ref005","unstructured":"The Global Fund to Fight AIDS Tuberculosis and Malaria. Pledges and contributions report, 2025 [cited 18 June 2025]. Available from: https:\/\/data-service.theglobalfund.org\/file_download\/pledges_contributions_report\/excel"},{"key":"pmed.1004946.ref006","article-title":"Final cuts will eliminate U.S. aid agency in all but name","author":"K Demirjian","year":"2025","journal-title":"The New York Times"},{"key":"pmed.1004946.ref007","article-title":"Utterly devastating: global health groups left reeling as European countries slash foreign aid","author":"G Galvin","year":"2025","journal-title":"Euronews"},{"key":"pmed.1004946.ref008","unstructured":"Global Coalition of TB Advocates. Rapid assessment on the impact of US government funding freeze on TB responses in selected high TB burden countries. 2025. 2025. [cited 18 June 2025]. Available from: https:\/\/gctacommunity.org\/news-events\/impact_funding_freeze_report.html"},{"key":"pmed.1004946.ref009","author":"World Bank","year":"2024"},{"issue":"9","key":"pmed.1004946.ref010","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"},{"issue":"4","key":"pmed.1004946.ref011","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(23)00045-1","article-title":"The impact of alternative delivery strategies for novel tuberculosis vaccines in low-income and middle-income countries: a modelling study","volume":"11","author":"RA Clark","year":"2023","journal-title":"Lancet Glob Health"},{"issue":"1","key":"pmed.1004946.ref012","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1004155","article-title":"The cost and cost-effectiveness of novel tuberculosis vaccines in low- and middle-income countries: a modeling study","volume":"20","author":"A Portnoy","year":"2023","journal-title":"PLoS Med"},{"issue":"7","key":"pmed.1004946.ref013","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2023-012466","article-title":"The potential impact of novel tuberculosis vaccines on health equity and financial protection in low-income and middle-income countries","volume":"8","author":"A Portnoy","year":"2023","journal-title":"BMJ Glob Health"},{"issue":"10","key":"pmed.1004946.ref014","doi-asserted-by":"crossref","DOI":"10.18637\/jss.v109.i10","article-title":"Emulation and history matching using the hmer package","volume":"109","author":"A Iskauskas","year":"2024","journal-title":"J Stat Soft"},{"key":"pmed.1004946.ref015","unstructured":"World Health Organization. WHO releases new global lists of high-burden countries for TB, HIV-associated TB and drug-resistant TB. 2021. [cited 2 Nov 2025]. Available from: https:\/\/www.who.int\/news\/item\/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-associated-tb-and-drug-resistant-tb"},{"issue":"1","key":"pmed.1004946.ref016","doi-asserted-by":"crossref","first-page":"558","DOI":"10.1038\/s41598-021-04345-x","article-title":"A systematic review and meta-analysis of the catastrophic costs incurred by tuberculosis patients","volume":"12","author":"RM Ghazy","year":"2022","journal-title":"Sci Rep"},{"issue":"11","key":"pmed.1004946.ref017","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(17)30341-8","article-title":"Catastrophic costs potentially averted by tuberculosis control in India and South Africa: a modelling study","volume":"5","author":"S Verguet","year":"2017","journal-title":"Lancet Glob Health"},{"issue":"7","key":"pmed.1004946.ref018","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001675","article-title":"Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru","volume":"11","author":"T Wingfield","year":"2014","journal-title":"PLoS Med"},{"key":"pmed.1004946.ref019","volume-title":"Protocol for survey to determine direct and indirect costs due to TB and to estimate proportion of TB-affected households experiencing catastrophic costs: field testing version","author":"World Health Organization","year":"2015"},{"key":"pmed.1004946.ref020","unstructured":"World Bank. World development indicators. Last updated: 15 Apr 2025. [Online] 2025 [cited 25 May 2025]. Available from: https:\/\/data.worldbank.org\/"},{"key":"pmed.1004946.ref021","article-title":"The concentration index (equation 8.1)","volume-title":"Analyzing Health Equity Using Household Survey Data","author":"O O\u2019Donnell","year":"2008"},{"issue":"5","key":"pmed.1004946.ref022","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1177\/0272989X12458348","article-title":"Model parameter estimation and uncertainty analysis: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force Working Group-6","volume":"32","author":"AH Briggs","year":"2012","journal-title":"Med Decis Making"},{"issue":"7","key":"pmed.1004946.ref023","article-title":"Where will it end? Pathways to care and catastrophic costs following negative TB evaluation in Uganda","volume":"16","author":"THA Samuels","year":"2021","journal-title":"PLoS One"},{"key":"pmed.1004946.ref024","article-title":"Shifting power in global health will require leadership by the Global South and allyship by the Global North","author":"M Pai","year":"2024","journal-title":"Lancet"}],"updated-by":[{"DOI":"10.1371\/journal.pmed.1004946","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T00:00:00Z","timestamp":1772150400000}}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004946","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T18:45:02Z","timestamp":1772217902000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004946"}},"subtitle":[],"editor":[{"given":"Madhukar","family":"Pai","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2026,2,20]]},"references-count":24,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2,20]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pmed.1004946","relation":{},"ISSN":["1549-1676"],"issn-type":[{"value":"1549-1676","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,20]]}}}