GLOBALLY, Pakistan ranks fifth among high tuberculosis-burden countries, with over 686,000 TB case notifications in 2023. On World TB Day, we urge health policymakers to acknowledge that TB is not just a health challenge but also an economic and social crisis, deeply rooted in poverty, inequity and social injustice.

TB disproportionately affects the poor, pushing vulnerable families into financial hardship whilst exacerbating existing social disparities. While a nationwide TB cost survey is still underway, there is compelling evidence to suggest that a significant proportion of TB-affected households face catastrophic healthcare costs (over 10 per cent of the household income), lost wages, and the inability to meet nutritional requirements during TB treatment.

Despite having social protection programmes such as the Benazir Income Support Programme (BISP) and the Sehat Sahulat Programme (SSP), TB-affected individuals remain largely excluded from these vital safety nets in Pakistan.

Pakistan has 95 million people living below the poverty line of $3.65 per day. According to the Pakistan National Nutrition Survey (2018), two out of every five children under five are stunted, nearly one in five suffers from wasting, and one in seven women of reproductive age is undernourished. This has serious health consequences, especially for diseases like TB. Growing evidence highlights their vicious bi-directional link, particularly in low- and middle-income countries, where over 80pc of TB cases occur. In fact, if your body mass index is below 18.5, your risk of contracting TB is much higher. Once infected, malnutrition worsens outcomes, making matters deadlier and recovery slower. But there is hope: the RATIONS trial in India (2019-2022) demonstrated that nutritional support can reduce new TB cases by nearly 40pc. Providing a daily food basket with 1,200 calories and 50 grams of protein — the equivalent of two plates of rice and lentils — could dramatically improve survival rates for TB patients.

TB patients remain largely excluded from vital safety nets.

On the contrary, Pakistan’s National TB Control Programne limits nutritional support to individuals with multidrug-resistant TB, leaving behind drug-susceptible TB patients. It is about time that a low-cost, high-impact approach to integrate TB treatment with financial and nutritional support is well-integrated with the TB control programming, if Pakistan is to come anywhere close to eradicating the disease.

Pakistan has a few available options for integrating social support models for persons with TB. The BISP Nashonuma scheme provides conditional cash transfers to children under two and pregnant and lactating women to improve health-seeking behaviour and nutritional intake. It offers Rs2,500 per quarter per pregnant and lactating woman and child in addition to food baskets. TB Champions should strongly advocate for the inclusion of persons with TB as a target population for this programme. Small cash transfers linked to treatment adherence and appropriate nutritional intake, could help mitigate the financial impact of disease. Conditional cash transfers, already used in several global TB programmes, have been shown to increase adherence to treatment and reduce default rates. By including TB patients in the existing BISP structure, Pakistan can provide financial relief without requiring the creation of an entirely new programme.

Another suggestion is to expand SSP to cover outpatient TB care that would further ensure free diagnostics and medication for those seeking care in the private sector. Currently, SSP provides inpatient hospital care but does not cover outpatient treatment, which forms the bulk of TB care. Given that primary care is essential in managing TB, expanding SSP to cover outpatient TB services in the private sector would bring TB care closer to the communities, greatly improving accessibility and affordability.

As donor support for TB dwindles globally, Pakistan needs to take action to integrate TB persons into existing domestically funded social protection schemes. India and the Philippines remain successful examples of such measures. Pakistan can significantly interrupt TB transmission by adopting similar approaches to TB care.The financial case of these interventions is clear. The costs associated with TB treatment failure, relapse, and increased transmission are far higher than the cost of preventive nutritional and financial interventions. TB patients need more than just medicines — they need a holistic care package that includes financial aid and appropriate nutrition. This may be the only missing piece in the puzzle of TB elimination in the country.

The writer is an assistant professor at the Aga Khan University. She is currently pursuing a doctorate in public health at the Johns Hopkins University. She has authored numerous scientific publications on TB.

Published in Dawn, March 24th, 2025