title: Association between spending on social protection and tuberculosis burden: a global analysis.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  National Institutes of Health National Center for Advancing Translational Science (University of California, Los Angeles [CA, USA] Clinical and Translational Science Institute).
authors.affiliation: Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, CA, USA; Global TB Programme, WHO, Geneva, Switzerland. Electronic address: sirokaa@who.int.
authors.forename: Andrew
authors.initials: A
authors.lastname: Siroka
authors.affiliation: Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, CA, USA.
authors.forename: Ninez A
authors.initials: NA
authors.lastname: Ponce
authors.affiliation: Global TB Programme, WHO, Geneva, Switzerland.
authors.forename: Knut
authors.initials: K
authors.lastname: Lönnroth
mesh_terms: D017281:Cost of Illness; D014943:Global Health; D005102:Health Expenditures; D006801:Humans; D015994:Incidence; D015995:Prevalence; D011640:Public Policy / Q000191:economics*; D014376:Tuberculosis / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control*