DAT products are increasingly used around the world in a variety of income settings to assist patients diagnosed with TB in adhering to medication regimens. This emerging market is an exciting development within the Global Health field and of interest to a wide range of stakeholders but currently not well understood and quantified. Through the process of market sizing, the ASCENT project aims to analyze and communicate key trends and opportunities in the global DATs for TB market.
Note: This work only explores potential use of DAT for one health condition – infection with TB. Other use cases for DAT are well-established and would increase the overall DAT market size but remain outside the scope of this analysis.
The global DAT for TB market is nascent, with high potential for future growth.
- Few existing DAT products are explicitly designed to target users in middle-or-low-income markets (LMICs) to support treatment of infectious diseases. For TB, demand for DAT is growing to address the ~9 million infections occurring annually across the world.
- Demand for DAT for TB will likely be highest in Asia and Africa, regions where TB incidence are highest. This geographic distribution may benefit existing manufacturers in South Africa and India, and encourage further innovation leading to locally adapted products.
However, growth of the DAT for TB market may be fragmented, favoring high burden countries with well developed health and information technology systems.
- At the country level, growth in the use of DAT to assist patients in adhering to TB medication regimens is predicated on high rates of TB diagnosis and high accessibility to information and communication technologies such as feature and smart phones.
- Potential demand in many LMICs, particularly in Sub-Saharan Africa, may be difficult to address without continual infrastructural investments (ex: expand availability of TB diagnostics, increase cellular and internet coverage particularly in rural contexts, etc…). Suboptimal cellular infrastructure can manifest in low population coverage and higher usage costs.
DAT products that require less information and communication technology access for use (ex: feature phone instead of smart phone) are better suited for the global DAT for TB market.
- LMICs with the highest need for DAT for TB tend to have considerably more feature phone users than smart phone users. Additionally, access to 3G+ cellular networks tend to be low in rural areas.
- There is still a market for smart phone based DAT in high-income countries and urban areas in LMICs, to meet user preferences. Deploying multiple DAT products within a country would necessitate interoperability in data management and platforms.
In countries where TB care-seeking in the private sector is high, integration of DAT into routine TB case management will require extensive public-private collaboration.
How big is the total DAT for TB market? Where is it concentrated?
There are many ways to define the global DAT for TB market and estimate its size. Theoretically, every person infected with TB has unmet need for treatment adherence support through use of DAT. Hence, the most logical starting point is by defining the market as the annual global incidence of TB, which is the total number of people who experience a case of active TB in a year. In 2019, this was estimated to be ~9 million people.
A significant portion of global TB burden is in Asia, a geography which encompasses the South-East Asia and Western Pacific regions (as defined by the WHO). Here, 4 of the top 5 countries by annual incidence in the world are found (India, China, Indonesia, and the Philippines). As decision-makers in high-burden countries push to meet targets set in the United Nations Sustainable Development Goals (SDGs), demand for innovative digital solutions to improve treatment adherence will continue to grow. We anticipate that National Tuberculosis Control Programs (NTPs) in these Asian countries will be major drivers in the long-term development of the DAT for TB market, and their procurement strategies may reshape the landscape of DAT manufacturing for TB and other health conditions (ex: management of non-communicable diseases), which is currently more concentrated in high-income, western countries.
The DAT for TB market in Africa is also substantial in aggregate. Annually, ~2 million cases of TB occur in the region. However, potential demand is more widely dispersed across countries relative to the Asian market. Additionally, infrastructural constraints such as limited cellular network coverage and internet access limit the applicability of many existing DAT products. These constraints will be explored in greater detail in later sections.
Use the interactive diagrams below to explore the distribution of global TB burden across countries and WHO regions. Select WHO region(s) in the bar chart to apply filters on the map. Hover over elements to review data in detail.
How much of the potential DAT for TB market is currently addressable?
In practice, not all persons infected with TB can use DAT (as currently designed) to address their need for treatment adherence support. To use most commercially available DAT, a person with active TB must be (1) diagnosed with the disease; (2) able to obtain appropriate medication to initiate treatment; and (3) have access to information and communication technologies (ICT) such as a cellular network or internet and/or feature phone or smart phone.
Data exists to factor in these addressable market constraints, in order to narrow in and enumerate potential DAT users for TB treatment adherence. We illustrate this calculation process, through which we arrive at the addressable market size for cellphone-based DAT (4.6 million) and smartphone-based DAT (2 million), in the Sankey diagram below.
In the tabs below, we explore these addressable market constraints in greater detail and analyze implications.
How does case detection affect addressable market size?
As illustrated in the figure below, the rate of case detection is not uniform from country to country, even within the same region. Generally speaking, health systems in high income countries tend to face much fewer cases of TB but have sufficient resources and capabilities to diagnose the vast majority. Conversely, health systems in lower income countries tend to face high TB burden but lack the resources and capabilities to achieve high case detection. In certain countries, such as Nigeria where TB case detection is below 30%, the TB burden potential addressable by DAT is greatly restricted.
Collectively, health systems around the world diagnosed roughly 2/3 of global incident TB cases. We estimate that ~5.8 million cases are potentially addressable by the global DAT market. Regionally, the drop-off between TB burden and diagnosed cases is most significant in Africa and South-East Asia, the two highest burden regions. Currently, we estimate that 58% and 72% of TB burden in these respective regions are potentially addressable by DAT.
How does access to ICT affect addressable market size?
All DATs are designed with the capability to routinely transmit data to a centralized database and require regular access to internet or telecommunications (ICT) networks for use. In highly developed contexts, where broad cellular and internet network coverage exists and smartphone ownership is high, ICT access is unlikely to significantly constrain addressable market size. In developing contexts however, lack of consistent ICT access and/or low market penetration of cellular technologies is a major limiting factor to addressable market size.
The aggregate impact of inconsistent ICT access on the global DAT for TB market is illustrated in the Sankey diagram above. In 2019, out of 5.9 million patients diagnosed with TB, we estimate that ~4.6 million patients had access to cellphones, of which only ~2 million had access to smartphones.
This trend is particularly notable in high TB burden countries in S.E. Asia and Africa. In India, the country with the highest TB burden, cellphone ownership is currently <70% and smartphone ownership is <30%. We would expect DATs predicated on smartphone capabilities, such as some Video Observed Therapy (VOT) options, to be inaccessible for the vast majority of patients diagnosed with TB.
Geographic equity in ICT access is also an important consideration as the DAT for TB market progresses. Globally, we estimate more than 1.2 million patients diagnosed with TB currently do not own cellular phones and/or live outside of existing ICT networks. The bulk of this market segment resides in rural areas, where ICT providers may lack market incentives to expand networks to cover in the near future.
Market size constraints in detail