The good news arrived in November. The WHO’s Global Tuberculosis Report 2025 showed that the number of people falling ill with TB fell by nearly 2 per cent between 2023 and 2024, and deaths fell by 3 per cent. The WHO African Region had cut its TB incidence rate by 28 per cent and deaths by 46 per cent since 2015. After the disruption of the pandemic years, the curve was bending the right way again.
The same report contained a second number that should worry anyone who has watched a disease come back from apparent defeat. In 2024, only US$5.9 billion was available for TB prevention, diagnosis and treatment in low- and middle-income countries. The target for 2027 is US$22 billion a year. We are funding the response at less than a third of what the world agreed it needs.
TB’s history suggests the most dangerous moment is not when it is surging. It is when it seems to be retreating, and budgets start to follow it down.
A disease that punishes impatience
Tuberculosis is not like measles, where a gap in coverage produces a visible outbreak within months. TB is slow. An estimated 10.7 million people fell ill with it in 2024, and 1.23 million died, according to the WHO. Many more carry latent infection that may activate years later. When a programme weakens, the damage accumulates quietly: missed diagnoses, interrupted treatment, more transmission in households, more drug resistance.
By the time it shows up in the statistics, it has been building for years. That lag is the core problem. It lets funders and finance ministries cut TB budgets and see no immediate consequence, while committing future governments to a larger epidemic.
There is a measurement trap inside the lag, too. TB incidence is not counted directly. It is estimated, largely from notifications, which are the people a programme actually finds and reports. When case finding shrinks, notifications fall. A falling notification number looks, on a ministry dashboard, exactly like a falling epidemic. For a year or two, a weakening programme can produce data that resembles success. Anyone reading next year’s figures should ask first whether the testing volume behind them held up.
The mechanism: why decline invites relapse
The pattern is old enough to have a name in public health: the U-shaped curve of neglect. It played out in New York City in the 1970s and 1980s, when TB control funding was dismantled as the disease receded, and cases climbed again, with multidrug resistance, until the city rebuilt its programme in the 1990s at far greater cost than maintaining it would have required.
The mechanism is not mysterious. Each stage of declining incidence makes the next stage of control more expensive per case, because the remaining cases are harder to reach. The easy patients, those who walk into a clinic with a cough, are found first. What remains are people in prisons, mines, informal settlements and remote villages, people with HIV whose TB presents atypically, and children whose disease is hard to confirm. At exactly the point where the marginal case costs more to find, budget committees see a smaller problem and ask why it needs the same money.
This is the incentive worth stating plainly. The political reward for TB control peaks when the disease is visible and frightening. The epidemiological need for it peaks later, in the long, unglamorous tail.
What the cuts actually mean
In 2025, the United States dismantled USAID, historically one of the largest bilateral funders of TB programmes, and several European donors announced reductions in development assistance. A modelling study in The Lancet Global Health, covering 79 countries that account for about 91 per cent of global TB incidence, estimated that ending USAID funding alone could lead to around 537,700 excess TB deaths by 2035. Adding the wider cuts announced by the US, France, the UK and Germany raised the projected toll further, to roughly a million additional deaths over the same period.
Models are not forecasts. They depend on assumptions about how quickly services degrade and whether domestic governments fill the gap. But the mechanism is not speculative. Fewer diagnostic tests mean fewer people found. Fewer people found means more transmission. More interrupted treatment means more resistance.
A rough way to see why the losses compound: a person with active, untreated pulmonary TB goes on infecting others for as long as the disease goes unnoticed, often many months. Suppose, purely for illustration, that each undiagnosed person infects a handful of contacts over a year, and that a small fraction of those infections progress to active disease over the following years. Every missed case then seeds a future cohort of cases, some of whom will also be missed. The arithmetic is not a single loss but a chain. That is why the models’ death counts stretch out to 2035 rather than landing in the year of the cut.
The strongest counterargument
The best case for the cuts is not callousness. It is a claim about ownership. Critics of donor-funded TB programmes have long argued that external money builds parallel systems: vertical programmes with their own staff, vehicles, reporting lines and salary top-ups, which domestic governments never budget for because someone else always has. On this view, a sudden withdrawal is painful but forces countries to put TB into their own health budgets, where it should have been all along.
That argument partly holds. Several middle-income countries with large TB burdens, including India, South Africa and Brazil, already finance most of their TB response domestically. The WHO report counts US$4.8 billion of domestic TB funding in 2024, of which the five BRICS countries provided US$3.1 billion. Ownership is possible. Dependence on a single donor is a real fragility, and the transition to domestic funding was always going to have to happen.
Where the argument fails is timing and sequence. A planned transition phases money down over years while domestic budget lines phase up. An abrupt stop leaves a gap in the middle, and TB is a disease in which gaps are the whole problem. Drugs already ordered are not delivered. Contracts for sample transport lapse. Trained community workers find other jobs and do not come back when funding does. A country can decide to own its TB programme; it cannot recruit and train a replacement workforce in the time it takes for a patient’s six-month regimen to be interrupted.
Drug resistance is the real ratchet
There is genuine progress on drug-resistant TB. The WHO reports that more than 164,000 people received treatment for drug-resistant TB in 2024, and treatment success rates rose to 71 per cent from 68 per cent a year earlier, helped by shorter, all-oral regimens.
But drug resistance is where a funding gap does its most lasting harm. Every patient who starts treatment and cannot finish it because the clinic ran out of drugs, or because the outreach worker who used to visit was let go, is a candidate for a resistant infection. Susceptible TB can be cured with a standard course of treatment. Resistant TB is longer, harder, more expensive, and in the worst cases may not be curable at all with current drugs. A budget cut today can create a patient who costs many times more to treat in five years.
The word ratchet is deliberate. Incidence can go down again once funding returns. Resistance does not reverse so easily. A resistant strain, once circulating in a community, is transmitted as a resistant strain. The new regimens that have made drug-resistant TB more treatable rely on a small number of drugs, and every poorly supervised course erodes their useful life. The cost of a stock-out is paid not only by the patient who misses doses but by everyone who later catches the strain that emerged.
This is the uncomfortable incentive underneath the whole issue. The savings from cutting TB programmes are booked now, by donors and treasuries. The costs arrive later, in someone else’s accounts, and in someone else’s lungs.
The overlooked gap: people who were never found
The WHO estimates that about 8.3 million newly diagnosed people received treatment in 2024, around 78 per cent of those estimated to have fallen ill. That means more than two million people with TB were either not diagnosed or not reported.
Those missing people are the engine of transmission. They are disproportionately poor, rural, incarcerated, living with HIV, or working in mines and informal jobs where a cough is not a reason to stop working. Reaching them depends on exactly the kinds of activities that are easiest to cut: active case finding, community health workers, transport support, contact tracing in households.
There is a second-order effect here that rarely makes it into budget memos. When programmes contract, they tend to retreat to facilities. Facility-based diagnosis is cheaper per test and easier to supervise, so it survives. Outreach does not. The result is a programme that keeps treating the people who come to it and stops looking for the people who do not. The share of missing cases grows, and the population that makes up that share becomes poorer and more marginal. Inequality in TB is not only an outcome of underfunding; it is the mechanism by which underfunding does its damage.
What each actor can actually do
Domestic governments cannot simply replace donor money overnight, but health ministries can decide what to protect first. The diagnostic chain comes first: rapid molecular tests, cartridges, sample transport and laboratory staff. Everything else depends on finding people. Drug supply is second, ring-fenced so that no clinic runs out mid-course, because stock-outs are the fastest route to resistance. Case finding should be budgeted as prevention rather than as an optional add-on, since finding one person early prevents the next several infections.
Finance ministries have a harder conceptual task. They need to count future costs in today’s decisions. A cut that raises drug-resistant cases in five years is not a saving; it is a loan at a punishing rate. Treasuries that use multi-year expenditure frameworks can model this. Most do not do it for TB.
For hospital and district health managers, the practical question is integration. Folding TB into primary care can save money and reach people who would never visit a dedicated TB clinic. It can also dissolve the expertise and reporting that make TB control work. The difference usually comes down to whether someone remains accountable for TB numbers after the merge.
Remaining donors and philanthropic funders, including the Global Fund, face a triage problem. Money spread thinly across every activity will fail everywhere. The better use of scarce external funds is probably the pieces that countries find hardest to finance themselves: commodities with volatile prices, new diagnostics, and bridging finance for the workforce during transition, tied to explicit domestic co-financing schedules.
Clinicians, finally, are the first to see the collapse, because they see the patient who returns sicker after a missed month, or the child whose contact was never traced. Their observations are an early warning system that most surveillance data will miss for a year or more. Programmes that collect those observations systematically will know sooner.
What to watch through 2027
Four signals will tell us whether the gains are holding. The first is testing volume, not just notifications: if the number of rapid molecular tests performed falls, any drop in reported cases should be treated as suspect. The second is stock-out reports for first-line and drug-resistant regimens at facility level. The third is treatment interruption rates, which will show up before resistance does. The fourth is domestic budget lines for TB in the high-burden countries that relied most heavily on US funding; if those lines do not grow in the next two budget cycles, the transition is not happening.
The next WHO Global Tuberculosis Report, due later this year, will cover 2025, the first year of the cuts. It will probably still look reasonable. The lag guarantees it. The report that matters more is the one after.
The takeaway
Tuberculosis has been declining because people kept paying for the dull, relentless work of finding and curing it. The report that showed progress also showed how thin the funding underneath it has become. Diseases like TB do not come back because science fails. They come back because success makes them look finished.
If you work in a TB programme, what has already changed on the ground since the funding cuts began? Share your experience below.
