Is convenience really king?Comparative evaluation of catastrophic costs due to tuberculosis in the public and private healthcare sectors of Viet Nam:a longitudinal patient cost study

Background In Viet Nam,tuberculosis(TB)represents a devastating life-event with an exorbitant price tag,partly due to lost income from daily directly observed therapy in public sector care.Thus,persons with TB may seek care in the private sector for its flexibility,convenience,and privacy.Our study aimed to measure income changes,costs and catastrophic cost incurrence among TB-affected households in the public and private sector.Methods Between October 2020 and March 2022,we conducted 110 longitudinal patient cost interviews,among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program(NTP)in Ha Noi,Hai Phong and Ho Chi Minh City,Viet Nam.Using a local adaptation of the WHO TB patient cost survey tool,participants were interviewed during the intensive phase,continuation phase and post-treatment.We compared income levels,direct and indirect treatment costs,catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression.Results The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort(USD 868 vs USD 578;P=0.010).However,private sector treatment was also significantly costlier(USD 2075 vs USD 1313;P=0.005),driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants(USD 754 vs USD 164;P<0.001).This resulted in no significant difference in catastrophic costs between the two cohorts(Private:55%vs NTP:52%;P=0.675).Factors associated with catastrophic cost included being a single-person household[adjusted odds ratio[(a OR=13.71;95%confidence interval(CI):1.36-138.14;P=0.026)],unemployment during treatment(a OR=10.86;95%CI:2.64-44.60;P<0.001)and experiencing TB-related stigma(a OR=37.90;95%CI:1.72-831.73;P=0.021)].Conclusions Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector.Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector,use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.