Is Tuberculosis Treatment Truly Free? A Study to Identify Key Factors Contributing to the Catastrophic Cost of TB Care in Pakistan

Background: The interplay between financial deprivation and tuberculosis (TB) is considered one of the vital socio-economic determinants of disease. This is the first study of its kind to be carried in Pakistan, which aims to identify leading factors contributing towards catastrophic costs of TB diagnosis and management in order to help policy makers. Methodology: From four tertiary care hospitals (TCH) in Islamabad and Rawalpindi, 400 TB patients were interviewed through a cross-sectional survey. The patient’s pre and post-TB income and direct and indirect costs for treatment were analysed following WHO recommendations. Multivariable logistic regression model was used to identify the determinants of catastrophic total cost. Results: For TB management expenditures, the median (interquartile range) of total costs by households was Rs. 58,175 Rs (32,050 - 97,500). At 20% threshold, 67% of TB patient’s households were affected by catastrophic costs. The determinants of the catastrophic total cost were as follows: patient/guardian employed (adjusted odds ratio [aOR] = 3.428, 95% confidence interval [CI]: 1.900 - 6.186), patient/guardian the only breadwinner (aOR = 1.751, 95% CI: 1.011 - 3.032), follow-up visits at current health facility (aOR = 1.352, 95% CI: 1.223 - 1.494), job loss (aOR = 3.381, 95% CI: 1.512 - 7.561), and unpaid sick leaves (aOR = 2.862, 95% CI: 1.249 - 6.558). Conclusion: The financial deprivation experienced by patients of low socio-economic status increases as TB treatment proceeds. This negatively impacts the treatment adherence, resulting in poor treatment outcomes due to income and job loss. Outcomes are exacerbated if the family has single breadwinner and treatment requires follow-up visits.