Investments in HIV, TB and malaria eased pressure on primary care

Tuberculosis, HIV and malaria have long been major drivers of illness and demand on health systems in low- and middle-income countries. Over the past two decades, targeted programs and funding to combat these three diseases — abbreviated HTM — have expanded widely. Jiaying Stephanie Su and collaborators set out to measure an often-overlooked effect of that expansion: whether scaling up disease-specific HTM services reduced the routine load on primary healthcare (PHC). The research focused on 108 low- and middle-income countries across the period 2000–2023. Instead of looking only at cases or deaths, the team estimated how many outpatient visits and inpatient bed-days in primary care would have been needed for people with symptomatic HIV, tuberculosis, or malaria who could not access HTM-specific services. To figure this out, they compared what actually happened as HTM coverage increased with a counterfactual scenario in which HTM service levels stayed the same as in the year 2000. The goal was to quantify the health-system relief delivered by HTM investments, and to translate that relief into direct cost savings for primary care services.

The researchers used established mathematical models for each disease to estimate primary healthcare utilization by people with symptomatic HIV, tuberculosis, or malaria who did not have access to HTM-specific care. For each country they compared two scenarios: the real-world scale-up of HTM services from 2000 to 2023, and a counterfactual that held HTM coverage at year 2000 levels. They then applied published unit costs to turn fewer visits and bed-days into monetary savings. Their results are substantial. From 2000–2023 the scale-up of HTM services is estimated to have averted 6.9 billion outpatient PHC visits (95% uncertainty interval [UI] 4.4–10.5 billion) and 3.9 billion inpatient bed-days (95% UI 2.5–5.9 billion). The team translates this reduced utilization into an estimated US$135 billion in averted primary care costs (95% UI US$71–250 billion). The largest reductions in utilization occurred in sub-Saharan Africa and in the East Asia and Pacific region. Across the 108 countries studied, the reductions equated to a median 4.4% of hospital bed capacity and 1.6% of government health spending in 2023; for low-income countries those medians were 22.9% and 5.1%, respectively. The analysis noted gaps in some input data, with missing values estimated by regression imputation.

These findings show that investments focused on HIV, tuberculosis and malaria can have wide benefits beyond the patients reached by disease-specific programs. By reducing the number of sick people turning to general outpatient services and hospital beds, HTM scale-up appears to have eased pressure on primary health care and freed up bed capacity and government funds, especially in the countries that carry the heaviest burdens. The estimated US$135 billion in averted PHC costs is a way to quantify a broader return on HTM investment that is not captured by disease counts or mortality figures alone. The authors caution that their study only measured changes in utilization and direct costs; it did not assess other ways PHC services might have changed, such as quality, staffing or the availability of non-HTM services. They also note that some country-level inputs were missing and filled in by regression imputation, which adds uncertainty. Still, the clear message is that sustained HTM funding in high-burden settings has likely delivered substantial system-level relief, a factor that policymakers and funders should weigh when evaluating past and future investments.