The 2025 Global Report is published - our analysis of some of its content

Each year we offer our analysis of the WHO’s Global TB report soon after it gets published. This year it’s appeared a little later than usual which already suggested to us that it might contain material that’s been more carefully reviewed than usual for the purposes of political expediencies, and after considering the Report’s contents we believe that this is probably the case. So, because some particular aspects of the Report are reported but are somewhat muted in the way they are messaged (and seriously worry us), we feel it to be important to attempt to fill some of these gaps, and then provide something of a megaphone for their implications.

The typical headline that has appeared when this publication has been reported on at all is typified by something like this - Global tuberculosis diagnoses rise to a record, and deaths fall, WHO reports.

Whilst the former statement is thankfully true (the number of TB cases put on treatment has indeed risen to a record high) the number of deaths is actually questionable because it exists as an estimate and depends on many uncertainties, in particular the estimate of the number of TB cases that are out there but are being missed, and also an estimate of how many of these missed cases are actually dying. Furthermore, it also depends on the amount of TB cases out there (both notified and missed) who are resistant to the existing cheap first line drugs because this also impacts any estimated predictions. So there is still much to be cautious about.

We are also cautious because, whilst both Dr Tedros (the Director General of the WHO) and Dr Kasaeva’s (the Director of the WHO’s TB Department) brief introductions are cautious and very carefully worded, The WHO Report’s official introductory Overview is actually disarmingly positive – “most indicators are moving in the right direction” it pronounces, suggesting that things are generally on the right track.

Whilst it’s true (that many indicators that are moving in a right direction) they are doing so abysmally slowly, and are self evidently catastrophic in respect of the goals that were set for this year as an illustration very clearly shows. What's more some are stalling.

Out of 11 of targets listed in the 2025 Report (and there are others, of c course, including for MDR-TB which aren’t listed in the Report at all as far as we can see), only three of them have managed to breach more than half of their designated target, and four of them languish at a quarter or less of their target. And perhaps it should be stressed that these sub-optimal achievements occur after a decade of concerted efforts. Of course, no-one should be pretending that defeating TB is easy, but claiming that “most indicators are moving in the right direction” does seem disingenuous in light of this, perhaps even misleading.

The mystery of the positive statements on MDR-TB

In respect of MDR-TB, in particular, the Report is almost casual: “Globally, the estimated annual number of people who developed MDR-TB or RR-TB (MDR/RR-TB) has been falling since 2015” (as it states on Page 9). It’s important to identify that all targets set by the UN in 2018 and 2023 for MDR-TB are still wildly off-track (and aren’t even identified in this current Report) and, what’s more, case detection rates and treatment success rates for MDR-TB are unsurprisingly still significantly deficient compared to ‘normal’ drug susceptible TB (unsurprisingly so because it is so much more challenging to detect and treat).

What everyone seems to forget (or ignore), though, is that we’ve been here before with MDR-TB – with the earlier targets that were set for 2015. One of the key targets for 2015 (a decade ago) was that 270,000 of confirmed MDR-TB cases would be being enrolled on treatment according to international guidelines by that year. That figure was abysmally missed in 2015, but shockingly it is STILL being missed today a decade later (with just under 165,000 MDR or proxy MDR cases put on treatment in 2024). Making matters even worse, at the UN High Level Meeting on TB in 2018 a commitment was made to “ensure 1.5 million people with drug-resistant TB (MDR-TB and XDR-TB) receive treatment by 2022” (i.e. between 2018 and 2022). This target, moreover, was seen as a “critical milestone” in ending TB by 2030, confirming how important finding and treating MDR-TB cases was seen to be back then. The target was obviously missed by 2022 (by a factor of around 60%, though it should be noted that the COVID pandemic had a hand in this). What’s concerning us, though, is that in 2019 the annual number put on treatment was 177,000 and last year it was under 165,000 – in other words MDR and proxy-MDR treatment still hasn’t reached the peak annual treatment of 2019 five years after the pandemic’s height

So are we right in being concerned? And are we right in wondering exactly what the provenance is of the Report’s perplexing estimate that “the annual number of people who develop MDR-TB has been falling since 2015”?  Exactly what has changed since 2018 that allows those in Geneva to make such a casual unambiguous statement because we’ve seen no justification for it? And so it disturbs us profoundly (especially since the claim that incidence rates of MDR-TB are made purely on the basis of estimates which are known to be deficient in respect of the relevant available global surveillance data).

The ‘funding landscape’

But it was the last sentence in the official Overview of the Report that amounts to being such a revealing understatement – that “Changes in the funding landscape threaten this progress”. Since these changes in funding landscape are carefully hinted at in both Dr Tedros and Dr Kasaeva’s introductions to the Report (but are not developed or extrapolated in terms of their implications) we feel it's worth taking on the challenge of exploring it for ourselves in what follows.

It’s certainly true that the Report makes it clear how badly the funding targets set by all UN member nations have been being missed in the last seven years: “Funding for the TB response remains grossly inadequate and has been stagnating” is the summary. This statement describes how funding for TB treatment programmes generally have only managed to grow to meet just a paltry 27% of the annual target set for last year (it was even worse before then) and funding for TB research to only 24% of its annual target.

Only matching a quarter of a budget that was unanimously agreed by all member nations seven years ago amounts to an appalling reflection of the typical political dereliction of duty that is so consistently awarded to this disease and to those most vulnerable to it. But those shortfalls were historic already as the year turned into 2025 and have been previously identified. It’s what has been happening more recently in respect of funding that deserves further highlighting.

Here’s how the Report summarised this current aspect in its Overview: “Cuts to international donor funding from 2025 onwards threaten overall funding for the TB response in many countries.” On page 26 of the Report it adds that: “Cuts to international donor funding for the TB response in 2025 now threaten the sustainability of current levels of TB prevention, diagnostic and treatment services” and it’s very clear to us that this is what Dr Tedros was hinting at in his brief preamble when he stated that “this is a crucial period” for TB (though Dr Kasaeva only complains of there being “persistent challenges” dogging progress, and not new and unexpected ones.

A page later the Report amplifies much more significantly concerning those “cuts in international donor funding … in 2025”, identifying that earlier this year “decisions by the government of the United States of America (USG) and wider political developments have resulted in cuts to international donor funding, including for health in general and TB specifically. In 2024, the USG was the largest contributor of funding to the Global Fund (about one third). It was also the largest bilateral donor for TB, providing grants to 24 priority countries. Through these two channels, the USG contributed about 50% of international donor funding for TB in the period 2015–2024.”

What the Report appears to have cautiously identified here is that ALL of these programmes for “health in general and TB specifically” are now in immediate jeopardy. Instead of highlighting what this almost certainly promises for those in the front line of TB control as many might expect, however, the Report rather meekly suggests that: “It remains too early for a reliable assessment of domestic and international donor funding for the TB response in 2025.” We assume that this Report’s cautious reporting of what amounts to probable catastrophic consequences because of changes in the funding landscape reflects a vain hope that this situation may soon revert to something nearer the former norm (which was already seriously deficient). Let’s hope so (though it does seem currently rather unlikely).

The Report does, however, include a projection of what some of the consequences might be in respect of deaths and new cases over the next decade – suggesting that 2.1 million extra TB deaths will occur and 5.6 million extra TB cases may emerge in the next decade if the American cuts aren’t reversed. This projection may satisfy some in Geneva, and indeed some in TB endemic countries, but we don’t consider that it does justice to the parlous situation for two reasons (and we think it could turn out to be MUCH worse.

One reason is because it doesn’t consider other cuts made by other donor nations (which the Report doesn’t mention at all) – cuts which may not be as swingeing as those made by the U.S. but which, given the U.S. government’s unilateral actions, may be equally savage since they serve to exacerbate the effects of those American cuts, not attenuate them.

But secondly, in line with many of our blogs on most of these Reports, we are always highly sensitised by what these Reports record in respect of MDR-TB, and so we immediately focus on the absence of any discussion in the Report on the impacts of these reductions in international donor support for MDR-TB programmes in TB endemic countries.

(We focus on MDR-TB this way simply because we consistently worry that the WHO downplays the true extent of the existing MDR-TB pandemic – and have posted blogs repeatedly on this. We remain convinced that the current estimates are are optimistic, are epidemiologically unlikely, and are probably under-pegged. The truth is that they are based on sub-optimal surveillance data, and (as the WHO know only too well from experience over the last thirty years) sub-optimal surveillance data has often necessitated revising previous estimates upwards, on some occasions quite dramatically.)

We also remain convinced that the prospects of ‘ending’ MDR-TB as a global threat by 2030 currently sadly amount to a pipe-dream because almost every aspect of MDR-TB is disproportionately under-funded when compared to ‘ordinary’ drug-susceptible TB. Furthermore, all targets set for it are being abjectly missed, and this aspect of the Global Emergency of TB is being too casually under-reported.

So, while the whole TB project appears to be on the brink of break-down because of these funding cuts it is the missing MDR-TB component that perhaps demands the most attention.

Why MDR-TB is now especially at risk

Here is why MDR-TB poses particular challenges.

• MDR-TB drug treatment is longer, more expensive, and less effective than drug-sensitive TB. In other words prospects of improvement are generally more fragile.

• MDR-TB comprises much ‘higher-hanging fruit’ than drug-susceptible TB because of the challenges involved in treating it successfully. In other words, if you are looking for quicker demonstrable good news story in TB (the sort that every politician craves) it’s logical to avoid focusing on MDR-TB and picking the lower hanging stuff.

• Adherence to drug treatment is generally lower with MDR-TB than with normal TB treatment because of challenging side-effects of second-line drugs. This makes diligent patient management especially important because failure to complete drug treatment doesn’t just mean higher mortalities, it also makes for increasing drug-resistance (to pre-XDR-TB and XDR-TB) and further ongoing transmission. And diligent patient management, of course, requires extra (unaffordable) resource.

• Inconsistent supply of second-line TB drugs for MDR-TB (and of diagnostics – cartridges for rapid diagnostic tests, for instance) also means higher mortalities, predictable increasing incidence of drug-resistance (leading to Pre-XDR- and XDR-TB strains that are even harder to treat) and once again further ongoing transmission.

• MDR-TB control relies on a different programme infrastructure to mainstream National TB Programmes – and these are highly vulnerable to national cut-backs for political expediency because of the higher requirements of both human and financial resource.

  
  

The huge recent funding cut-backs

The most shocking impacts are, of course, as a consequence of American policy changes on foreign aid as the current administration strives to make its home country ‘great again’. Two specific examples have had enormous impact and must have created shockwaves in Geneva:

1.       The U.S. withdrawing from the WHO

2.       The U.S. peremptorily dismantling USAID

It’s unquestionable that federal actions, ranging from the dismantling of USAID to illegal grant suspensions and/or terminations, have had a profound and direct impact on TB already. But the withdrawal of the U.S. from the WHO itself has more complex implications still (not least of which is the relatively cautious critique of U.S policies in this recent Report for fear, we suspect, of political backlash and an increasingly vulnerable organisation struggling with its own in-house future funding as a result).

The first sign of these changes was on January 20, 2025, when President Trump signed Executive Order 14155, officially directing the United States to withdraw from the WHO. He cited several reasons for this order including the WHO’s alleged mishandling of global health crises, its perceived political influence from other member states, and the disproportionate financial contributions demanded by it from the U.S.. Immediately  after this Order was signed the country’s Centers for Disease Control and Prevention (CDC) ceased all collaboration and communication with the WHO, but U.S. participation in WHO-led initiatives was immediately suspended too, including in global health surveillance, something which must have already had profound impact on policy development in respect of global MDR-TB.

And this is before USAID was peremptorily dismantled as well. But the U.S is not the only party whose hands are stained by international funding reductions.

The UK has also significantly reduced its contributions to global TB control. Thankfully (unlike America) it is still active in the game, recently pledging £850 million to the Global Fund to Fight AIDS, Tuberculosis and Malaria for 2026–2028, but this is nowhere near enough to make a difference given the catastrophe for TB that arises from current U.S. policy. What’s more this pledge is itself 15% down from the UK’s previous £1 billion pledge in 2022 and over 40% down from its previous £1.46 billion given in 2019. (And we need to note that the Global Fund is a major source of financial support for MDR-TB programs worldwide).

The EU, meanwhile, has also reduced its funding. The exact scale of EU-specific cuts to MDR-TB is harder to clarify than those of either the UK or U.S., but EU member states generally have cut back on their funding support to several crucial global institutions which include both the Global Fund and the WHO, both of which are critical for supporting health programmes that include MDR-TB.  Such funding, including from the EU, has been accounting for 62% of TB funding in low-income countries, for example, and any reduction in this support directly undermines these countries’ MDR-TB programmes (which are already deficient anyway).

A share of these EU aid budgets, meanwhile, has been quietly redirected towards defence and other geopolitical priorities which themselves have been prompted by pressure from American foreign policy shifts. Countries like France and Germany in particular have scaled back such international commitments citing inflation, energy crises, and domestic political pressures as reasons, all of which are real pressures domestically and may make sense to their domestic electorates, but are of much less significance proportionately if compared to any typical TB endemic country.

Here is what reduced EU funding does to MDR-TB control:

·       It weakens the backbone of MDR-TB programs in Africa and Eastern Europe, which rely on it for diagnostics, drug procurement, and community support

·       It leads to treatment interruptions, slower case detection, and so to increased transmission of drug-resistant strains.

Typical effects of funding cuts that are already being seen in Africa

• Active case‑finding campaigns and mobile outreach are being curtailed, reducing early detection of MDR cases.

• Community‑based peer support programmes are being scaled back, increasing frequencies of missed doses and defaults.

• Procurement delays for second‑line drugs are creating local stockouts or reliance on older, more toxic regimens.

• Weaker lab supply lines mean longer turnaround for drug‑susceptibility testing.

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It’s important to stress how these effects do not seem to have been appropriately highlighted in the new WHO TB Report, and we believe that they should have been. In fact, a cursory review of the text of the Report would even suggest not just that incidence of MDR-TB is reducing, but that it's actually not that much of a problem in Africa, and that the region generally has been working as well as any in moving towards meeting the targets set by the UN for TB for 2030!

Typical effects of funding cuts that are already being seen in Eastern Europe and in the EU ‘neighbourhood’

 Of course, it’s not just the region of Africa and its high proportion of low-income countries that’s at risk from MDR-TB. BRICS countries and other middle-income ones (China, Russia, South Africa, Brazil, the Philippines and Indonesia, for instance) are all known to have high numbers of MDR-TB cases but it should be noted that the TB programmes in these countries are largely funded domestically with only a small proportion of their TB budgets supplied by donor nations. In this sense these countries should be less affected by these cuts, in other words.

The countries which are known to have the highest proportions  of MDR-TB in their TB epidemics, however, are countries that comprised parts of the former Soviet Union – countries like Azerbaijan, Moldova, Georgia, Kazakhstan and indeed Russia itself. In some of these countries as much as 50% of new TB cases are now MDR (or worse) – and it’s noteworthy that some of these former Soviet oblasts actually border the EU. We’ve previously argued that these countries (with their higher proportion of MDR-TB cases) offer a more real picture of the future of MDR-TB than the WHO generally offers in its Reports, and our view of this prospect remains the same.

Well, here is what is already being reported in these countries:

• Slower roll‑out of rapid molecular diagnostics is occurring as is the roil-out of the crucial newer all‑oral MDR regimens (the most effective and most tolerable second-line treatments for MDR-TB).

• Strains are emerging on regional reference labs and drug‑resistance surveillance, weakening detection of pre‑XDR/XDR trends (MDR-TB, or at least ‘proxy MDR-TB, may be relatively easily detected by a rapid molecular assay test but more extensive drug-resistance - i.e. to more than just the strongest TB drugs - requires sophisticated expensive testing in designated labs). XDR-TB (which is resistant to some second-line TB drugs as well as first-line ones as well as the more recent drugs added to the armoury) was once described by the WHO’s own TB czar as “probably the most dangerous thing we could ever have imagined”. More recently, however, it attracts little focus in WHO Reports despite its threat remaining real, and its incidence (we think) is almost certainly under-estimated and logically must be rising.

• Reduced funding for integrated services (mental health, social protection) is undermining adherence among TB patients with complex social needs. It’s often forgotten that those most at risk from TB (and MDR-TB in particular) are also most at risk from many other aspects of survival.

• Worrying coordination gaps are emerging for cross‑border patients and continuity of care for displaced populations.

Colliding crises – war and conflict, climate change, debt, alarming erosions of human rights, and deepening inequalities – all of these are unquestionably contributing to the threat of reversing the slow collective progress that’s been made in the fight against TB. And these crises are no longer far distant. In the immediate EU ‘neighbourhood’ many people have fled their homes, causing internal displacement and movement across borders. Losing access to health care is just one devastating consequence of such displacement but it’s not difficult to appreciate that this can swiftly become a life-threatening issue. Meanwhile, in the countries themselves, crucial testing, treatment and prevention services have been disrupted for those left behind, while health systems are becoming overwhelmed and understaffed.

As a result, many people – particularly including children with TB, people with latent TB, and patients with drug-resistant TB – face yawning treatment gaps. At the same time this whole ‘neighbourhood’ of the EU is also being confronted by higher prices, product gaps and supply vulnerabilities, and drug-resistant TB once more remains a huge obstacle in effectively ending the TB epidemic in the region.

Ukraine

In Ukraine the war has only inflamed this challenge. Here the under-resourced Global Fund has been struggling to help fund critical work required to preserve, maintain and strengthen health care and community systems and ensure patients have ongoing access to prevention, testing and treatment for TB.

In Ukraine, incidentally, 31% of new tuberculosis (TB) cases and 46% of previously treated TB cases are MDR-TB, with Southeastern Ukraine consistently showing the highest MDR-TB rates, and Central Ukraine also seeing spikes in incidence due to war-related disruptions. (Globally, just 3.6% of new tuberculosis (TB) cases and 17% of previously treated TB cases are estimated to be MDR).

The Middle East (including Syria and Gaza)

The Global Fund has also been allocating over US$54.4 million under the Middle East Response Initiative (2023-2025) to provide essential health services to key and vulnerable populations including refugees, internally displaced people, women and children. This funding certainly helps bolster progress in TB prevention, treatment and care, and what’s more contributes to building more resilient health and community systems. Before and since this Initiative was established in 2017, moreover, the Global Fund has disbursed around US$280 million in funding to the countries included in this Initiative.

In Syria about 12% of new TB cases are reckoned to be MDR-TB, rising to 36% in previously treated cases (well above the global averages of 3.6% and 17% respectively). Treatment success rates for those undergoing treatment for MDR-TB, meanwhile, is well below the global average.

It’s not difficult to imagine that these numbers are conservative because of years of war severely weakening Syria’s health infrastructure, limiting access to diagnostics, medications, and reducing trained personnel while millions of internally displaced persons (IDPs) and refugees face barriers to consistent TB treatment with inevitable risks of resistance increasing.

Meanwhile limited access to both rapid molecular testing and drug susceptibility testing delays appropriate treatment initiation which also inevitably means longer and more extensive circulation of infectious drug-resistant strains.

The Global Fund’s Middle East Response Initiative, meanwhile, has also been supporting interventions that have included aiming for the 'elimination' of TB in both Jordan and Palestine. These programmes are now in obvious disarray, particularly in Gaza where it’s difficult to imagine any TB programme currently operating. The most recent estimates reckoned that around 11% of new TB cases in Gaza were MDR-TB, rising to 27% in previously treated ones. Treatment success rates were known to already be below the global average before the current conflict and genocide began – they must be abysmally below the global average by now if such treatment programmes are even surviving under current conditions.

In summary

In summary, this is what is promised for the short-term future of MDR-TB control by these frightening funding cuts by richer donor nations (and is not identified in the crucial TB Report):

• In diagnostics and detection. Reduced money → fewer GeneXpert cartridges, reagents and sample shipments → less active case finding and delayed drug‑resistance confirmation → more people start inappropriate first‑line therapy while resistant strains spread.

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• In drug procurement and supply chains. Smaller or delayed budgets → interrupted purchasing of second‑line and newer MDR regimens → stockouts, forced regimen substitutions, or treatment pauses that drive treatment failure and further resistance.

• In community care and adherence support. Cuts to grants for community health workers, social enablers, transport and nutritional support → fewer treatment visits, higher default rates on long MDR regimens, and lower treatment success.

• In laboratory and surveillance capacity. Funding shortfalls stall maintenance, accreditation, and expansion of reference labs and molecular testing networks → slower resistance surveillance and poorer ability to target effective regimens.

• In programme management and workforce. Reduced technical assistance, training and salaries → loss of key staff, weaker data management, and lower quality of clinical oversight.

• In cross‑border and vulnerable‑group services. Less regional funding harms continuity of care for migrants, refugees, and displaced people and weakens cross‑border referral systems, increasing transmission risk in border regions.

  
  

Short‑ to medium‑term public‑health consequences

• Fewer MDR-TB diagnoses and a predictable rise in undetected transmission.

• Increased treatment interruptions and poorer treatment outcomes.

• Higher probability of amplification to more severe resistance (pre‑XDR/XDR-TB).

• Greater long‑term cost: higher mortalities or more complex care needed later, higher burden on already stretched health systems.

  
  

A Lancet Global Health study recently modelled that “reductions in donor funding could substantially increase TB morbidity and mortality, with MDR-TB patients being disproportionately affected due to the complexity and cost of their treatment”. ‘No shit, Sherlock!’, as the saying goes.

We fear that this recent WHO TB Report sadly comprehensively fails to adequately identify the risks of such increases.

And since specific commitments were made in 2023 at the more recent High Level Meeting at the UN to “address TB during health and humanitarian emergencies”, doing so by “safeguarding TB services as essential health services during humanitarian and health emergencies” all to be done at the same time as making a parallel commitment to “address the crisis of drug resistant TB” we think it right and proper to call this out for what it is – an impending public health disaster.

And sadly this summary conclusion doesn’t remotely suggest that we have a situation that indicates that “things are moving in the right direction”.