TB remains the world’s deadliest infectious disease. The paediatric burden is more than just a statistic — it is a verdict on our collective failure. But a radical shift in how we finance the TB response could change everything.
The Epidemic That Should No Longer Exist
In 2025, tuberculosis (TB) killed more people than any other infectious disease—even though we have had effective ways to diagnose and treat it since the mid-nineteenth century. This is a failure of will, systems and, above all, financing.
South Africa carries one of the heaviest TB burdens in the world: 767 new cases diagnosed every single day. Among them, 29 children start treatment daily. Yet, treatment coverage for children is just 47% – meaning more than one in two children with TB are never reached by treatment. Each childhood diagnosis does not merely represent a sick child; it represents stunted early development, months of school missed, a family’s income halted, and a community’s future eroded.
While progress has been made with improved diagnostics, shorter treatment regimens, and community-based screening programmes, a stubborn and damning truth persists, South Africa’s national TB programme — and those of us implementing it — are failing children.
Children: Our Most Honest TB Indicator
When a child develops TB disease, they were likely infected by an adult in their immediate environment – proof that we have not prevented transmission in time. The paediatric TB burden is not a separate problem to be solved with paediatric-specific interventions, rather, it is a direct reflection of how well, or not, we are managing the epidemic in adults.
A landmark Lancet Global Health paper published this year by Coleman et al introduced the concept of the tuberculogenic environment – the sum of the structural, socioeconomic, commercial, and health system factors that sustain TB transmission in vulnerable communities. Overcrowded housing, undernutrition, indoor air pollution and HIV co-infection creates financial precarity that forces sick people to delay accessing care. Most of these drivers are upstream of anything health systems can fix on their own. However, finance departments, agriculture ministries and housing infrastructure are rarely in the room when TB strategy is being written.
Children cannot protect themselves from tuberculogenic environments. Their risk of infection is our accountability. Despite this, South Africa has been able to reach treatment success rates of about 70% through intensive community-based interventions, an opportunity we should build on.
What Works
Since 2020 AQUITY has conducted over 40,000 digital chest X-ray screenings for TB annually — deploying 11 mobile X-ray units across the provinces with the heaviest burden of TB. This was part of South Africa’s response to missing TB cases. These implementation models detect cases early to reduce transmission and generate granular spatial and epidemiological data that help guide targeted interventions to where they will have the greatest impact. We need to generate evidence that includes children.
What Coleman et al and local experience agree on is that aggressive find-and-treat strategies, community-wide active case finding, contact tracing and preventive treatment activities require ‘major population mobilisation and funding commitment that national tuberculosis programmes might be unable to broker.’ The infrastructure and the evidence exist. The financing does not match the ambition.
Paediatric TB diagnostics remain underfunded and under-deployed. Child-friendly formulations of key drugs, particularly for drug-resistant TB, have arrived late and remain inaccessible in many settings. Decentralised care — allowing children to be diagnosed and initiated on treatment close to home — is the exception rather than the rule. The result is delayed diagnosis and treatment, preventable complications and deaths in children who rely on us to protect them.
The Financing Catalyst We Need
The question that should be dominating every conversation in the lead-up to World TB Day is: if we know what works, what is stopping us from ending the TB epidemic?
In our view, the answer is the absence of an overarching framework on financing the TB response long term, with a view to making investments now that will lead to better outcomes and savings.
Inadequate domestic investments arising out of a severely constrained government budget means that the financing regime (Medium Term Expenditure Framework set in a decadal austerity plan) can only deliver funding for the TB response at current levels. Donor dependency and the recent signals of declining donor investments create fragility that makes long-term planning almost impossible. This is evident from the shockwaves sent through TB programmes worldwide by the recent United States withdrawal from global health financing. National health budgets, perpetually squeezed, cannot easily absorb the upstream, multi-sectoral investments required to address the tuberculogenic environment driving the TB epidemic.
Outcomes-based financing offers a compelling way through this impasse. The logic is elegant: private investors provide upfront capital for proven interventions, implementing organisations deliver at scale, independent evaluators verify measurable outcomes, and government pays only when those outcomes are confirmed. These instruments raise capital at attractive rates in the domestic market and focus the investments on measurable outcomes.
Social bonds are gaining ground in South Africa. The SAMRC’s Imagine Social Bond, funded by the National Treasury, demonstrated that high performance results can be achieved while social investors carry the risk of failure – proving the financing model is both real and replicable. The project also signals the Treasury’s openness to innovative financing instruments and its commitment to outcome-based payment.
For TB eradication specifically, the economics are compelling. Every case prevented saves the fiscus an estimated R120,000 to R300,000 in lifetime treatment costs. Every child protected from a disease that could cause lifelong lung damage preserves future productivity and tax revenue. Conservative estimates suggest R10 to R15 billion in investable TB prevention outcomes.
The Public Investment Corporation, managing R2.3 trillion in assets on behalf of South Africa’s public sector workers, has both the investment horizon and the regulatory mandate under the Pension Funds Act — which permits pension funds to invest in infrastructure and social assets — to treat health financing as a strategic priority. There is no shortage of investor interest in the capital markets, and as shown by the Imagine SIB, a growing community of social investors willing to take lower financial returns if social impact can be measurably demonstrated, in addition to taking on the risk of underperformance and project failure.
What the Children Are Telling Us
Every child diagnosed with TB is a messenger: TB transmission continues. We have the science to read these messages and the systems to respond. What we require is a financing architecture robust enough to sustain the response for the decade it will take to achieve TB elimination.
South Africa is on track to meet its 2030 adult TB targets, the result of years of hard work by national programme staff, implementing partners, researchers, and the communities who have invited us into their lives. But the paediatric picture tells us we are not finished – more than 50% of children are still being missed.
World TB Day asks us every year to remember what this epidemic costs in human lives. This year, let us also ask what ending it would be worth — in fiscal savings, in productive years recovered, in futures that children deserve. Using outcomes-based financing architecture makes TB elimination not an aspiration, but a business plan. Together, we can end TB!
About the Authors
- Dr Sipho Nyathie: CEO of AQUITY Innovations NPC | Public Health Organisation
- Prof. Fareed Abdullah: Dir Office of AIDS and TB Research | South African Medical Research Centre
- Prof Karen Du Preez: Associate Professor, Department of Paediatrics and Child Health, Stellenbosch University | Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University
- Dr Razia Gaida: Research Associate, Centre for Community Technologies |Nelson Mandela University
Key Reference
Coleman M, Calderwood CJ, et al. ‘The tuberculogenic environment.’ The Lancet Global Health, Vol. 14, March 2026, e444–e454.
