Forecast: The Impact of USAID Tuberculosis Cuts

by Kati Conen

Tuberculosis is the most deadly infectious disease in the world. It killed 1.2 million people in 2023, most in Africa and Asia. This is not because the disease is untreatable — it can be cured with a multi-month course of antibiotics — but because of limited access to diagnostic tests and treatment. Because access to tests is poor, many cases go undiagnosed. A vaccine exists, but it is effective only in children, and only against some forms of TB. Complicating matters further, TB can remain latent for years before converting into an active case, making it challenging to track the source of an infection.

Despite these challenges, TB outcomes have been steadily improving. Since 2000, the rate of new cases has decreased by 26%, access to diagnosis and treatment has expanded, and yearly deaths have fallen by more than 50%. In children, progress has been more rapid: Nearly 90% of newborns in impacted regions receive a TB vaccine, which has led to a greater than 80% reduction in child TB mortality. While the number of multidrug-resistant (MDR) cases has increased, treatments are becoming more successful, and continued research may produce another generation of effective TB drugs.¹ If progress continued at its current rate, the number of deaths from TB would keep declining by approximately 74,000 deaths per year.

The USAID funding freeze will almost certainly change these trajectories. Until 2025, USAID was one of the major contributors in the fight against TB, providing approximately 25% of all TB-focused international aid. As of this writing, more than half of that funding has apparently been eliminated.² Many countries are already reporting disruptions in screening, diagnosis, drug delivery, and treatment support. It is unclear at what level funding will resume, but between massive cuts to staff and contractors, delays in restarting payment systems, and the shutdown of overseas offices, it is likely that remaining programs will substantial administration challenges.

My goal is to forecast the effect of the USAID funding cuts on TB mortality. For simplicity, I’ll focus primarily on two timepoints: (1) the first year of reduced or absent USAID funding, and (2) the cumulative effects of USAID funding cuts over five years.³

How will USAID cuts affect TB mortality?

Modern international efforts to fight TB rose in the early 2000s with the signing of the UN Millennium Development Goals and the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria. From 2001 to 2005, funding for TB control more than doubled. TB mortality fell from 2.6 million to 2.3 million deaths per year over the same period — progress from rising mortality in the 1980s and ‘90s. Progress against TB has grown steadily over the past two decades, and in its 2024 Global Tuberculosis Report, the WHO estimated that TB treatment in HIV-negative patients saved 41 million lives between 2010 and 2023. The combination of TB treatment and antiretroviral therapy saved another 6.8 million lives in HIV patients.

How much of this progress was due to USAID funding? Approximately 20% of global TB funding comes from international aid. USAID contributions historically composed about 25% of that, or around 5% of total TB funding. Taken together, these estimates suggest that USAID’s TB programs prevented approximately 146,000 deaths per year in HIV-negative people (171,000 total, if the combined effects of TB-treatment and ART are counted).⁴ Accounting for the uncertainty in WHO estimates gives me a range of 129,000-164,000 deaths prevented by USAID funding per year in HIV-negative patients, or 150,000-192,000 deaths if all cases are included.

If we assume, as CGDev has estimated, a 57% cut to USAID TB funding, this represents 74,000-93,000 deaths per year in HIV-negative patients, or 86,000-109,000 total.

This gives me a rough estimate of USAID’s impact on TB mortality in the past, but we shouldn’t necessarily expect deaths to increase proportionally. Some benefits of TB funding — improved health care infrastructure and reduced disease prevalence — build over time and may persist even after cuts. However, slashing support will immediately impact staffing, testing, and medication access in low- and middle-income countries. And because TB treatment has become more effective in recent years, models based on past data may underestimate the impact of current funding.

We can see how these factors interact by looking at a similar case in the recent past. In 2020, global funding for TB decreased by roughly 10% as countries reallocated resources to their COVID-19 response. That year, TB deaths, which had been falling by about 74,000 each year globally, increased by 59,000. Thus, a 10% reduction in funding led to approximately 133,000 additional deaths from TB after one year.

If we assume 57% of USAID TB funding has been cut and USAID accounts for 5% of all global TB funding, that corresponds to an absolute funding decrease of 2.9%. Naively, you might expect that these cuts would then have approximately 29% as much impact as the COVID-19 cuts (comparing a 2.9% drop in total funding with the 10% during COVID-19), equivalent to 39,000 deaths over one year.

However, we need to adjust this for a few factors. Funding cuts during COVID-19 weren’t uniform across countries, and some countries rely more than others on USAID funds. What we really need to know is how TB funding and mortality changed in the countries most dependent on USAID: WHO-designated high-TB burden and TB-watchlist countries that rely heavily on international funding for their TB programs. For brevity, I’ll call these “focal countries.”⁵

Focal countries rely on international aid for more than half of their TB budget, and they received roughly 72% of the USAID funding for TB in 2023. They also account for slightly over half of TB deaths globally, despite comprising only 23% of the world population. Changes in mortality within these countries may have an outsized effect on the number of deaths overall.

In 2020, focal countries reduced domestic TB funding by approximately 30%. International aid partially counterbalanced these cuts, which left a funding reduction of around 10% overall. As a result of cuts, many cases went undetected or unreported, and TB deaths in focal countries increased by 28,000.⁶ Over the previous five years, deaths in these countries had decreased by an average of 41,000 per year. Thus, based on these estimates, funding cuts in focal countries during COVID-19 led to 69,000 additional TB deaths over one year.

Since USAID funding primarily goes to countries with high TB burden, these numbers suggest that the impact of USAID cuts would be worse than our naive estimate of 39,000 a year. Focal countries relied on USAID for about 15% of their TB budget in 2023. Thus, a 57% cut to USAID TB programs represents an 8.6% decrease in the annual TB budgets for these countries. If the effects are proportional to the 2020 cuts (which led to a 10% reduction in funding), then USAID funding cuts will lead to 59,000 additional deaths in focal countries alone over the next year. After adjusting for the uncertainty in our current estimates of funding cuts, this translates to 48,000-68,000 excess deaths over one year.

We also need to estimate the impact of the other 28% of USAID funding which goes to non-focal countries — which has primarily been split between India, South Africa, and Ukraine, with a few small grants to other countries. Based on TB burden, funding levels, and fatality rates,⁷ I suspect that USAID programs in India and South Africa have equal or greater impact than grants in focal countries. Grants to Ukraine may have a lower immediate impact on mortality, but they mitigate the tail risk of new MDR-TB outbreaks. Taken together, I estimate that the average impact of USAID funding in these countries is 90% as high as grants to focal countries. Extrapolating from the effect of COVID-19 cuts, this suggests that one year of USAID cuts will lead to 80,000 (65,000-92,000) total deaths worldwide.⁸

How comparable is the USAID freeze to COVID-19 cuts?

My estimates to this point have assumed that the impact of USAID freezes will be comparable to the impact of COVID-19 cuts regarding increased mortality. How valid is that assumption, and should I revise my estimate?

COVID-19 overwhelmed health care systems and disrupted supply chains, which probably exacerbated the effects on programs for TB diagnosis and treatment. Lockdowns may have led to some reduction in spread — health care centers observed reductions in the incidence of other respiratory diseases — but the impacts of reduced funding and access to care almost certainly outweighed this effect. Overall, the circumstances surrounding COVID-19 probably made the impact of TB funding cuts substantially worse than they would have been in isolation.

But the wholesale cuts to USAID also impact the entire health sector. Other USAID programs support health care and surveillance systems and fund work against diseases like HIV and malaria, which greatly increase the risk that latent TB converts into active infection, and that active TB becomes fatal. On top of these factors, TB case rates have not fully recovered from their increases after COVID-19. Higher incidence means that any increase in case fatality rate will translate to a greater number of additional deaths.

In addition, many of the contractors and suppliers responsible for carrying out USAID-funded work have been damaged by the 40-day funding freeze and slow restoration of payments. Disruptions to supply chains and program delivery may be difficult to recover from, reducing the operational capacity of remaining aid programs.

It’s difficult to get a clear sense of how all of these factors will interact, but my estimate is that cuts to TB funding in the current environment will be 1.5 to 1.9 times worse than they were during COVID-19. Adjusting my forecast upwards based on this impression, I estimate that cutting USAID funding for TB will lead to 98,000-175,000 additional deaths over the first year.

Compounding effects: Forecasting TB deaths over five years

Assuming the proposed funding cuts persist over the next five years, what does that mean for TB mortality?

The first effect of losing TB funding is a sharp decrease in coverage, or the proportion of people with TB who have access to diagnosis and treatment. Reduced coverage quickly translates to increased mortality: More TB cases go undetected, undetected cases can’t be treated, and approximately half of untreated patients die.

This rise in undetected cases is the primary driver of excess deaths during the first year. As TB cases go untreated, they also increase its spread. The impact of increased transmission is initially hidden — TB can remain latent for months or years before becoming an active infection, so changes in disease incidence are minor during the first year. But as disruptions to screening and diagnosis continue, more latent cases convert to active TB, and disease incidence will rise. If coverage remains low, many of these excess cases will also go undiagnosed and untreated, leading to further increases in transmission and, over time, greater mortality.

Once again, we can use COVID-19 to see how these variables respond to changes in funding. In 2020, TB case fatality rates rose from 12.8% to 13.6% as resources for programs were cut.⁹ This effect was relatively transient — case fatality rates decreased in 2021 as funding recovered, and they reached pre-COVID-19 levels by 2022. But while fatality rates fell, the disease continued to spread. TB incidence fell in 2020, but it began rising steadily in 2021. As of 2023, the last year with available data, TB incidence was still increasing, though the WHO predicted that the trend would level out or reverse within the next one to two years.

To get a sense of how USAID cuts may impact incidence and case fatality rates, I can again compare the scale of COVID-19 cuts and USAID cuts using focal countries as a reference point. I’ll assume that changes to TB incidence and fatality rate are proportional to the impact on mortality. As we saw in the previous section, COVID-19 cuts decreased focal countries’ budgets by 10%. USAID makes up 15% of their budgets, and an estimated 46-65% of USAID has been cut. This means that the current cuts are between 69% and 98% as high as COVID-19 cuts.¹⁰

I need to adjust for the fact that focal countries account for approximately 50% of TB deaths worldwide and receive 72% of USAID funding, and that I think the remaining 28% of funding is approximately 0.9 times as effective. Combining all these factors, I get an initial estimate that the impact of USAID cuts will be approximately 47-66% as severe as changes during COVID-19.¹¹

There are a few other factors I need to account for. First, TB incidence remains elevated compared with pre-COVID-19 levels. While the WHO predicted that incidence would stabilize or fall starting in 2024-2025, higher case numbers mean that increases in case fatality rates — which we expect as a result of cuts — will lead to more deaths. Second, according to the WHO, lockdowns and quarantine measures during COVID-19 reduced TB spread by roughly 50% while they were in place. In the absence of this mitigating factor, we should expect TB transmission in 2025 to be substantially higher than 2020.

In addition to these differences, it isn’t entirely clear how changes in incidence and case fatality rates will progress over five years. The COVID-19 cuts were recent and relatively brief. The current changes to USAID show signs of lasting much longer. Will persistent reductions in TB funding lead to indefinite increases in TB incidence from year to year, or will case rates plateau at a “new normal” based on remaining funding levels? How will case fatality rates change after the initial spike? Fatality rates started to recover relatively quickly after COVID-19 cuts, but the rebound in funding from 2021 to 2023 may have contributed to that. While local programs and bridge funds are trying to compensate for the current USAID cuts, it’s unclear how well they will be able to fill the gaps. Moreover, increased rates of HIV, malnutrition, and other TB risk factors may lead to more severe cases of TB.

To account for this uncertainty, I consider optimistic, pessimistic, and intermediate trajectories for case fatality rates and TB incidence. Case fatality rates always rise in the first year, but under the optimistic trajectory, they gradually recover after that. In the intermediate scenario, they remain relatively stable after the initial increase. In the pessimistic scenario, they continue to rise at a slow rate.

My optimistic trajectory assumes that the number of new cases reaches a plateau at around 11.8 million new cases per year — worse than current levels, but substantially better than an uninterrupted increase. This would be comparable to case rates at 2016 levels, adjusted for the expected world population in 2027.

In the intermediate scenario, incidence plateaus at 12.5 million, comparable to 2014 case rates. In contrast, the pessimistic scenario assumes that TB incidence continues increasing at a steady rate over the full five-year period.

In addition to these overall trajectories, I also considered more or less optimistic values for baseline TB incidence and expected transmission rates relative to COVID-19. I compared outcomes from these scenarios with the trajectories expected before funding freeze, using trends in incidence and fatality rate trajectories from 2015 to 2019 as a reference point.

Under the most optimistic assumptions, the USAID cuts will lead to approximately 1.1 million extra deaths from TB over the next five years (0.9 to 1.2 million). This scenario assumes that incidence increases can be controlled and that existing programs continue to make progress on case fatality rates after the initial disruption. For intermediate and pessimistic trajectories, 1.5 to 2.5 million people will die because of USAID TB cuts.¹² My intuition is that actual outcomes will be closest to the intermediate scenario, but there is a high degree of uncertainty. The trajectory may become clearer over the next one to two years as we see how well local programs can adapt.

Sources of uncertainty in the short and longer term

My forecasts have many sources of uncertainty, and they may be possible to refine with better information. I’m not an expert on the ground and could easily be missing important information about the current situation. Relatedly, my forecasts haven’t made a detailed account of all of the ways that withdrawal of USAID technical expertise and supply-chain support may exacerbate the effects of funding cuts, though I’ve tried to consider those factors when comparing the impact of current cuts with the funding reduction during COVID-19.

Are there any ways to mitigate the effects of reduced USAID TB funding? Local programs are trying to fill the gaps: looking for alternate funding, shifting government resources, finding ways to procure drugs and test supplies locally. Several middle-income countries have been in the process of developing strategic plans for domestically funded TB control, but it may take some time to develop and implement those plans.

Even with these contributions, replacing lost TB program funding may be challenging. The Global Fund, which provides most international aid for TB, has historically received approximately one-third of its funding from the United States. For now, Global Fund contributions have survived the cuts and are included in the list of retained awards. But a leaked memo suggests that the State Department wants to dedicate $800 million per year to the Global Fund in future years, paid out at a rate of $1 for every $4 contributed by other sources. Based on the current funding levels, the reduced payout rate would effectively reduce the US contribution by half. If this comes to pass, reductions to Global Fund contributions could double the effect on mortality of the USAID freeze on TB.

If the funding gaps left by USAID cannot be met, the effects on TB outcomes could become much worse. Reduced diagnostic coverage and interruptions in drug supply will probably lead to substantial increases in multidrug-resistant TB. Loss of programs for monitoring and surveillance makes it more likely that these MDR cases will spread to other regions, further increasing infections and deaths in future years. Even for drug-sensitive cases, disruption to treatment and testing will increase the spread of new cases, leading to lasting impacts on TB incidence and mortality. In the long term, interruption to TB research may lead to even greater losses, making it harder to move forward with the best candidates for new TB drugs and vaccines.

Conclusion

Progress in reducing the incidence and mortality of tuberculosis has been the result of deliberate, coordinated action by the international community. Withdrawing support from USAID could reverse that progress. My forecast predicts that 98,000-184,000 people will die from cuts to USAID TB programs over the next year. If these cuts are maintained at the same level, I expect TB program cuts will lead to 0.9-2.5 million deaths over the next five years. Conversely, restoring and maintaining aid funding would provide the opportunity to save these lives and to affect the continued trajectory of TB outcomes. These values are comparable to recent estimates from researchers from Stop TB, though slightly more pessimistic in the long term.¹³ The divergence over longer timelines may reflect different assumptions about how case fatality rates could change over the longer time range.

Even if USAID funding is restored, these events highlight some of the risks of relying too heavily on any single source of international aid. Along with restoring funding from USAID, it may become increasingly important to expand contributions from a wide range of national and private sources, building a greater capacity and more robust systems to fight TB and other major health threats globally.

---

Kati Conen is a biology researcher who has been involved in forecasting for the past six years. She placed second out of 1339 on the ACX 2024 Prediction Contest, and has placed in the top five on four tournaments since 2023. She can be found on Metaculus under the username katifish.

1. The current generation was brought to market beginning in 2012, the first new TB drugs in 50 years.

2. CGDev estimates a 57% cut, with a range between 46% and 65%.

3. I am not an expert in global health or international aid. If you’re familiar with the situation on the ground, you probably have a better picture than I do of the work TB programs do, as well as their vulnerability to unpredictable changes in support. What I hope I can offer is a general approach to making predictions about a complex and uncertain future, along with an overhead view of the concrete impact this loss of this funding will have on deaths across the world.

4. 41 million x .05 = 2.05 million between 2010 and 2013, or 146,429 lives saved per year.

5. These consist of Angola, Bangladesh, Cambodia, the Central African Republic, the Democratic People's Republic of Korea, the Democratic Republic of the Congo, Ethiopia, Gabon, Indonesia, Kenya, Lesotho, Liberia, Mongolia, Mozambique, Myanmar, Namibia, Nigeria, Pakistan, Papua New Guinea, the Philippines, the Republic of the Congo, Sierra Leone, Thailand, Uganda, the United Republic of Tanzania, Vietnam, Zambia, and Zimbabwe. Brazil, Russia, India, China, and South Korea also have high TB burden, but they rely less on international funding for TB control and are discussed separately in WHO Global TB Reports.

6. Funding cuts during COVID-19 began roughly three months into the year, so estimates based on these numbers may be 25% lower than they would be for a full year of reduced funding.

7. India and South Africa have more domestic funding for TB than focal countries, but both have extremely high TB burden, making additional access to treatment particularly valuable. India accounts for more new TB cases than the entire continent of Africa and was responsible for 26% of total TB deaths in 2023. South Africa has fewer TB cases than India, but only because their population is less than 5% as large. Adjusting for population, the case rate in South Africa is more than twice as high as in India, and their TB death rate is among the highest in the world. The situation in Ukraine is slightly different: TB burden is lower, but the displacement of refugees and disruption of health care services have contributed to an ongoing outbreak of MDR-TB that shows signs of spreading to neighboring countries. On top of that, high rates of HIV comorbidity are leading to a case fatality rate comparable to South Africa’s.

8. Non-focal countries receive 0.28/0.72 as much USAID funding as focal countries, so deaths in those countries = 59,000 * (0.28/0.72*0.9) = 20,650; 59,000 + 20,650 = 79,650, or roughly 80,000.

9. Compared with a decline of 0.6% from 2019 to 2020.

10. 46% and 65% of 15% = 6.9% and 9.8%, respectively, compared with the 10% reductions during COVID-19.

11. Focal countries: (69% to 98% of COVID-19 cuts) * (50% of global mortality) = 35% to 49% of total COVID-era effects. Non-focal countries: (.28/.72 the funding of focal countries) * (0.9 funding effectiveness) * (35% to 49% effect in focal countries) = 12% to 17% of the total COVID-era effect.

Combined estimate: (35% to 49%) + (12% to 17%) = 47% to 66% total effect.

12. Intermediate: 1.5 to 1.8 million excess deaths. Pessimistic: 1.9 to 2.5 million excess deaths.

13. They estimated that the full removal of USAID TB funding would lead to ~269k deaths over one year and 2.2 million over the next six, or 153k and 1.1 million when adjusted for the ~57% cuts now expected).