The benefits of investments to combat HIV, tuberculosis and malaria for primary health care, 2000–2023: an economic modeling analysis

Background Global investments to combat HIV, tuberculosis, and malaria (HTM) have delivered substantial health gains, and may have reduced the burden placed by these diseases on the routine health system. We estimated the reduction in primary health care (PHC) utilization resulting from the scale-up of HTM services over 2000–2023 in 108 low- and middle-income countries.

For each disease, we applied established mathematical models to quantify PHC utilization (outpatient visits and inpatient bed-days provided outside of HTM programs) by individuals with symptomatic HIV, tuberculosis, or malaria unable to access HTM-specific services. For each country, we estimated averted PHC utilization by comparing a scenario describing the actual scale-up of HTM services to a counterfactual scenario holding HTM service coverage constant at year 2000 levels. We applied published unit costs to estimate the averted costs resulting from reduced PHC utilization. Findings Over 2000–2023, scale-up of HTM services averted an estimated 6·9 (95% interval: 4·4–10·4) billion outpatient PHC visits and 3·9 (2·5–6·1) billion inpatient bed-days, representing US$135 (70–248) billion in averted costs. These reductions were greatest in Sub-Saharan Africa and East Asia and Pacific regions. Across study countries, these reductions represented a median of 4·4% of hospital bed capacity and 1·6% of government health spending in 2023. These percentages were 22·9% and 5·1% respectively for low-income countries. Interpretation Over recent decades, sustained investments in HTM services in high-burden settings have averted substantial PHC utilization and associated costs. These benefits should be considered when assessing investment impact. Funding The Global Fund. Competing Interest Statement Funding for this study was provided by the Global Fund. TBH and PW report funding from the MRC Centre for Global Infectious Disease Analysis, funded by the UK Medical Research Council (MRC). JSS, SS, PW, and NAM acknowledge support from the Bill & Melinda Gates Foundation. NAM also reports support from the U.S. National Institutes of Health, U.S. Centers for Disease Control and Prevention, and the European Commission. Funding Statement NAM, TBH, CP, JS, and PW acknowledge support from the Global Fund to Fight AIDS, TB, and Malaria. PW acknowledges support from the Bill & Melinda Gates Foundation (INV-043624). TBH and PW acknowledge funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/X020258/1), funded by the UK Medical Research Council (MRC). This UK-funded award is carried out in the frame of the Global Health EDCTP3 Joint Undertaking. JSS, SS, and NAM acknowledge support from the Bill & Melinda Gates Foundation (INV-004737). Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes Main text edited; cost estimates, tables, and figures updated; additional sensitivity analyses included; author information finalized; supplementary appendix added; funding and COI information revised. Data Availability All data produced in the present study are available upon reasonable request to the authors.