Catastrophic total costs in tuberculosisaffected households and their determinants since Indonesia’s implementation of universal health coverage

Background:As well as imposing an economic burden on affected households,the high costs related to tuberculosis(TB)can create access and adherence barriers.This highlights the particular urgency of achieving one of the End TB Strategy’s targets:that no TB-affected households have to face catastrophic costs by 2020.In Indonesia,as elsewhere,there is also an emerging need to provide social protection by implementing universal health coverage(UHC).We therefore assessed the incidence of catastrophic total costs due to TB,and their determinants since the implementation of UHC.Methods:We interviewed adult TB and multidrug-resistant TB(MDR-TB)patients in urban,suburban and rural areas of Indonesia who had been treated for at least one month or had finished treatment no more than one month earlier.Following the WHO recommendation,we assessed the incidence of catastrophic total costs due to TB.We also analyzed the sensitivity of incidence relative to several thresholds,and measured differences between poor and non-poor households in the incidence of catastrophic costs.Generalized linear mixed-model analysis was used to identify determinants of the catastrophic total costs.Results:We analyzed 282 TB and 64 MDR-TB patients.For TB-related services,the median(interquartile range)of total costs incurred by households was 133 USD(55-576);for MDR-TB-related services,it was 2804 USD(1008-4325).The incidence of catastrophic total costs in all TB-affected households was 36%(43%in poor households and 25%in non-poor households).For MDR-TB-affected households,the incidence was 83%(83%and 83%).In TB-affected households,the determinants of catastrophic total costs were poor households(adjusted odds ratio[aOR]=3.7,95%confidence interval[CI]:1.7-7.8);being a breadwinner(aOR=2.9,95%CI:1.3-6.6);job loss(aOR=21.2;95%CI:8.3-53.9);and previous TB treatment(aOR=2.9;95%CI:1.4-6.1).In MDR-TB-affected households,having an income-earning job before diagnosis was the only determinant of catastrophic total costs(aOR=8.7;95%CI:1.8-41.7).Conclusions:Despite the implementation of UHC,TB-affected households still risk catastrophic total costs and further impoverishment.As well as ensuring access to healthcare,a cost-mitigation policy and additional financial protection should be provided to protect the poor and relieve income losses.

Effect of financial support on reducing the incidence of catastrophic costs among tuberculosis-affected households in Indonesia:eight simulated scenarios

Background:The World Health Organization's End Tuberculosis Strategy states that no tuberculosis(TB)-affected households should endure catastrophic costs due to TB.To achieve this target,it is essential to provide adequate social protection.As only a few studies in many countries have evaluated social-protection programs to determine whether the target is being reached,we assessed the effect of financial support on reducing the incidence of catastrophic costs due to TB in Indonesia.Methods:From July to Septem ber 2016,we interviewed adult patients receiving treatment for TB in 19 primary health centres in urban,sub-urban and rural area of Indonesia,and those receiving multidrug-resistant(MDR)TB treatment in an Indonesian national referral hospital.Based on the needs assessment,we developed eight scenarios for financial support.We assessed the effect of each simulated scenario by measuring reductions in the incidence of catastrophic costs.Results:We analysed data of 282 TB and 64 MDR-TB patients.The incidences of catastrophic costs in affected households were 36 and 83%,respectively.Patients'primary needs for social protection were financial support to cover costs related to income loss,transportation,and food supplements.The optimum scenario,in which financial support would be provided for these three items,would reduce the respective incidences of catastrophic costs in TB and MDR-TB-affected households to 11 and 23%.The patients experiencing catastrophic costs in this scenario would,however,have to pay high rem aining costs(median of USD 910;[interquartile range(IQR)662]in the TB group,and USD 2613;[IQR 3442]in the MDR-TB group).Conclusions:Indonesia's current level of social protection is not sufficient to mitigate the socioeconom ic im pact of TB.Financial support for income loss,transportation costs,and food-supplem ent costs will substantially reduce the incidence of catastrophic costs,but financial support alone will not be sufficient to achieve the target of 0%TBaffected households facing catastrophic costs.This would require innovative social-protection policies and higher levels of dom estic and external funding.