USAID funding cuts increase financial burden for families with tuberculosis

More than a year after the second Trump administration began dismantling the US Agency for International Development (USAID), the global health consequences of this unprecedented loss in international aid continues to surface. A new study led by a Boston University School of Public Health researcher found that the funding cuts associated with USAID as well as other foreign aid, could substantially increase the financial burden among families affected by tuberculosis (TB) in low- and middle-income countries (LMICs).

Published in PLOS Medicine, the study estimated that the loss of USAID support could generate about $7.5 billion in additional costs for LMIC households that include at least one person diagnosed with TB. An additional four million households could experience "catastrophic costs," defined by the World Health Organization's (WHO) End TB Strategy as costs that include related medical and nonmedical costs, as well as indirect costs, that exceed 20 percent of a person's annual household income.

In an alarming worst-case scenario, if all international funding for TB ceased, the economic burden could reach almost $80 billion.

Prior to 2025, international aid played a significant role in ensuring access to TB prevention and treatment services, particularly for patients and their families in limited-resource settings. USAID, which has been credited with helping to prevent nearly 75 million deaths, provided nearly 20 percent of funding for TB services in other countries. International programs such as the Global Fund to Fight AIDS, TB, and Malaria (Global Fund) supplied 76 percent of funding, more than one third of which was also supplied by the US. This support resulted in quantifiable progress: Between 2023 and 2024, the global rate of people being infected by TB declined by nearly two percent and deaths from TB fell by three percent.

As the world approaches the annual day of observance for TB on March 24, the new study underscores the immense and urgent need for a restoration in global support for TB services.

These findings highlight how international funding has played a critical role in expanding access to TB diagnosis and treatment. Without sustained support from donors such as USAID and the Global Fund, many countries could see disruptions in essential TB services, leading not only to worse health outcomes, but also to severe financial hardship for families-particularly the poorest households."

Dr. Allison Portnoy, study lead and corresponding author, assistant professor of global health at BUSPH

For the study, Dr. Portnoy and colleagues from Harvard T.H. Chan School of Public Health, the London School for Hygiene & Tropical Medicine, and the University of Glasgow School of Health and Wellbeing estimated future TB costs to patients using linked epidemiological and economic models for 79 LMICs. They calculated these estimates considering six potential funding scenarios: continuation of 2024 funding levels; termination of USAID; termination of USAID plus announced US reductions in Global Fund contributions; termination of USAID plus complete termination of Global Fund contributions from the US; termination of USAID plus announced reductions in Global Fund contributions from all donor countries contributing one percent or more to the budget; and full elimination of external funding for TB. 

The household financial burden in the estimated worst-case scenario represents a 32-percent increase in costs prior to last year's funding cuts. The calculations showed that these costs were greatest among very low-income families, with more than half of the additional catastrophic costs falling upon the poorest 20 percent of households.

A TB diagnosis can impose multiple types of costs on families, particularly when the patient is experiencing an active infection, Dr. Portnoy says.

"First, there are direct medical costs, such as payments for medicines, tests, or consultations," she says. "Even where treatment is subsidized, patients may still face charges for diagnostic tests or supportive care."

Families also juggle direct non-medical costs, such as transportation to clinics, accommodation when traveling for care, and food or nutritional supplements needed during treatment. But often, the most significant costs are indirect costs-particularly income losses, Dr. Portnoy says, as TB frequently prevents people from working for extended periods due to illness or the demands of treatment.

"The immediate effects of these costs can include depleted savings, borrowing money, or selling assets to cover expenses. Over the longer term, this can push households into medical impoverishment, disrupt children's education, reduce food security, and create lasting economic instability."

The researchers note that the estimated totals are limited by certain assumptions or uncertainties, such as a lack of information on the true costs that untreated TB patients face, as well as how healthcare costs for all TB patients may change over time. But the scenarios detailed in the study capture the possible and range of consequences that could occur as a result of scaled-back international support. Other studies have also estimated potential extreme ramifications of foreign aid cuts to TB; a previous BUSPH study determined that US funding cuts could result in an additional nine million pediatric TB cases and 1.5 million deaths. 

Sustained foreign aid remains critical, but the researchers highlight other policy changes that could offset this financial burden if international funding continues to decrease.

"Countries may need to strengthen domestic financing and health system capacity to reduce reliance on external donors over time," Dr. Portnoy says. "This could include increased government investment in national TB programs and stronger integration of TB services into primary healthcare systems. Financial protection measures for patients-such as transportation support, cash transfers, or social protection programs-can help offset the indirect costs of illness and treatment."

Lastly, she says, transition strategies for donor funding should be gradual and coordinated, allowing countries time to mobilize domestic resources and maintain continuity of care. "Blended financing models that combine domestic funding, private sector engagement, and targeted donor support may help sustain TB programs during this transition."