Assessment of financial protection mechanisms for tuberculosis services in seven priority countries of the Western Pacific Region: a cross-sectional mixed-methods study

Abstract

Abstract Background Tuberculosis (TB) remains a major public health and socioeconomic challenge in the Western Pacific Region. Despite the expansion of universal health coverage (UHC), TB-affected households continue to face financial hardship. This study aimed to assess and compare financial protection mechanisms for TB services across the continuum of care in the region. Methods We conducted a cross-sectional mixed-methods study in seven TB priority countries in the Western Pacific Region: Cambodia, China, Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines, and Viet Nam. Data were collected between January and March 2025 through a structured online questionnaire and semi-structured interviews with 21 key informants. Findings were analysed using a standardised health financing framework covering revenue raising, pooling, purchasing, and service coverage. Secondary data from the WHO Global TB finance database were used to assess funding composition and donor dependence. Results Countries were mapped into three financing typologies: tax-funded systems, government-subsidised mixed systems, and insurance-based pooled systems. Total TB funding in 2023 varied widely, from US$3.7 million in the Lao People’s Democratic Republic to US$1.08 billion in China. External donor dependence was high in the Lao People’s Democratic Republic, Viet Nam, Cambodia, and Papua New Guinea, but minimal in China. Coverage of TB services was strongest for drug-susceptible TB treatment and weakest for radiology, hospitalisation, and services subject to social health insurance co-payments. TB preventive treatment and drug-resistant TB services were frequently sustained through donor financing. Interviews identified implementation barriers including pre-diagnostic user fees, reimbursement delays, fragmented purchasing, and incentives for unnecessary hospitalisation. Conclusions Expansion of UHC has not consistently translated into comprehensive financial protection for TB patients. While many TB services are nominally covered, patients remain exposed to costs through pre-diagnostic fees, co-payments, reimbursement limits, and donor-dependent service components. Strengthening financial protection requires integrating TB services into pooled domestic financing, removing avoidable cost-sharing for essential TB services, and aligning purchasing mechanisms with patient-centred TB care pathways.