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Association between spending on social protection and tuberculosis burden: a global analysis

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Summary

Background

The End TB Strategy places great emphasis on increasing social protection and poverty alleviation programmes. However, the role of social protection on controlling tuberculosis has not been examined fully. We analysed the association between social protection spending and tuberculosis prevalence, incidence, and mortality globally.

Methods

We used publicly available data from WHO's Global Tuberculosis Programme for tuberculosis burden in terms of yearly incidence, prevalence, and mortality per 100 000 people, and social protection data from the International Labour Organization (ILO), expressed as the percentage of national gross domestic product (GDP) spent on social protection programmes (excluding health). Data from ILO were from 146 countries covering the years between 2000 and 2012. We used descriptive assessments to examine levels of social protection and tuberculosis burden for each country, then used these assessments to inform our fully adjusted multivariate regression models. Our models controlled for economic output, adult HIV prevalence, health expenditure, population density, the percentage of foreign-born residents, and the strength of the national tuberculosis treatment programme, and also incorporated a country-level fixed effect to adjust for clustering of datapoints within countries.

Findings

Overall, social protection spending levels were inversely associated with tuberculosis prevalence, incidence, and mortality. For a country spending 0% of their GDP on social protection, moving to spending 1% of their GDP was associated with a change of −18·33 per 100 000 people (95% CI −32·10 to −4·60; p=0·009) in prevalence, −8·16 per 100 000 people (−16·00 to −0·27; p=0·043) in incidence, and −5·48 per 100 000 people (−9·34 to −1·62; p=0·006) in mortality. This association was mitigated at higher levels of social protection spending, and lost significance when more than 11% of GDP was spent.

Interpretation

Our findings suggest that investments in social protection could contribute to a reduced tuberculosis burden, especially in countries that are investing a small proportion of their GDP in this area. However, further research is needed to support these ecological associations.

Funding

National Institutes of Health National Center for Advancing Translational Science (University of California, Los Angeles [CA, USA] Clinical and Translational Science Institute)

Introduction

Tuberculosis is a major global health problem, with more than 9·6 million new cases and 1·5 million related deaths occurring annually.1 WHO's Stop TB Strategy 2006–15 focused on six strategic areas with an aim to reduce tuberculosis prevalence and mortality by 50% relative to 1990 levels.2 The centrepiece of this strategy was to expand and enhance access to quality diagnosis and treatment of tuberculosis, address multidrug-resistant (MDR) tuberculosis and tuberculosis–HIV co-infection, strengthen health systems, engage with public and private health-care providers, empower patients, and promote research.

The target of the Millennium Development Goals to halt and reverse tuberculosis incidence has been achieved on a worldwide basis. Additionally, the ambitious targets of halving tuberculosis prevalence and mortality by 2015, relative to 1990 levels, have almost been reached. Since 1990, global tuberculosis prevalence has fallen by 42% and global mortality has fallen by 47%.1 Despite this progress, the fall in tuberculosis incidence has been very slow—with an estimated decrease of 1·5% per year in global incidence of tuberculosis during 2000–13. This slow decrease has led to a greater focus on programmes and policies outside the traditional curative approach within the health-care delivery sphere.

The new End TB Strategy was adopted in May, 2014, by the World Health Assembly and sets out the interventions needed to end the global tuberculosis epidemic by 2035.3 This strategy places a greater emphasis on prevention and care of tuberculosis through addressing the social determinants of the disease, including policies to alleviate poverty, and social protection programmes. The International Labour Organization (ILO) describes social protection as “nationally defined sets of basic social security guarantees which secure protection aimed at preventing or alleviating poverty, vulnerability and social exclusion”.4 This definition covers protection against general poverty and social exclusion, and protection against a shortage of affordable access to health care, labour market protections, and work-related income. Examples of social-protection programmes are cash transfers (both conditional and unconditional), free or subsidised health care, food rations, disability pay, maternity leave, housing subsidies, and labour market protections.

Research in context

Evidence before this study

We searched PubMed for English-language articles published between 2005 and 2015 with the terms “social protection AND tuberculosis” or “tuberculosis AND poverty”. Many studies assess the link between poverty and tuberculosis; however, we only identified a few publications that analysed the relation between social protection and the disease. Other than this literature search, we relied on the methods used by the study by Reeves and colleagues on social protection and tuberculosis rates in Europe. Furthermore, our conceptual model was heavily driven by previously reported research on the link between poverty, malnutrition, and overcrowding, and research into these conditions as risk factors for tuberculosis.

Added value of this study

This study shows that an inverse association exists between social protection spending and the prevalence, incidence, and mortality of tuberculosis. To our knowledge, ours is the first study to do so with a global perspective, and to comment particularly on the association between social protection spending and tuberculosis burden in settings with few social protection programmes in place.

Implications of all the available evidence

National tuberculosis programmes should consider proactive dialogue and interaction with national social protection programmes run by other divisions of government than ministries of health, and with non-governmental organisations. This research gives evidence for tuberculosis-funding donors, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, to support the funding of social protection interventions outside the medical sphere in an effort to control tuberculosis.

To achieve long-term epidemiological goals, more emphasis is needed on interventions that reduce people's susceptibility to tuberculosis infection and progression from infection to active disease.5 Despite a call for further research, only a few studies have investigated the relation between social protection and tuberculosis burden, especially in developing countries that have the highest disease burden.

Results from a study reported in The Lancet Infectious Diseases by Reeves and colleagues6 examined the association between social protection levels and national tuberculosis control in 21 European countries. The investigators examined data from 1995 to 2012 using tuberculosis statistics from WHO and social protection data from the European Union (EU) database, EuroStat. The country–year analysis showed an inverse association between social protection spending and tuberculosis incidence (r=–0·65, p=0·0003) and mortality (r=–0·62, p=0·0104). Reeves and colleagues reported an association between social protection and tuberculosis in wealthy nations with large social protection systems and secure welfare mechanisms. Our study builds on this research by analysing this association with a global purview. We aimed to examine the association between levels of social protection, measured as the percentage of national gross domestic product (GDP) spent on social protection programmes (excluding health) and national tuberculosis estimates of prevalence, incidence, and mortality.

Section snippets

Data sources and study design

For this global analysis, we obtained social-protection data from the publicly available database of the ILO's Social Protection Department.7 To produce its World Social Protection Report, ILO provides a global overview of social protection systems, their coverage, benefits, and public expenditures. The underlying sources for these data are international organisations such as the International Monetary Fund, Organisation for Economic Co-operation and Development (OECD), and EuroStat. The data

Results

The mean values of key covariates by World Bank income group were weighted by each country's population over the years 2000–12 (table 1). Generally, high-income countries tended to allocate a greater proportion of their GDP to social-protection programmes than low-income countries (figure 1). Several countries in western Europe expended more than 20% of their GDP on social protection. Low-income and middle-income countries tended to spend proportionally less on social protection, but two

Discussion

Our findings show a clear ecological association between social protection spending (as a percentage of GDP) and tuberculosis prevalence, incidence, and mortality. This was especially true in settings with low levels of social protection spending.

Because of the ecological nature of this study, we cannot show a causal association between social-protection spending and tuberculosis burden. However, the inverse association shown in this analysis supports further research in this area. Bolstering

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