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.

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.

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.

The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal

Background:The World Health Organization(WHO)End TB Strategy has established a milestone to reduce the number of tuberculosis(TB)-affected households facing catastrophic costs to zero by 2020.The role of active case finding(ACF)in reducing patient costs has not been determined globally.This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding(PCF),and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal.Methods:The study was conducted in two districts of Nepal:Bardiya and Pyuthan(Province No.5)between June and August 2018.One hundred patients were included in this study in a 1:1 ratio(PCF:ACF,25 consecutive ACF and 25 consecutive PCF patients in each district).The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs.Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20%of their annual household income.The intensity of catastrophic costs was calculated using the positive overshoot method.The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs.Meanwhile,the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis.Results:Ninety-nine patients were interviewed(50 ACF and 49 PCF).Patients diagnosed through ACF incurred lower costs during the pre-treatment period(direct medical:USD 14 vs USD 32,P=0.001;direct non-medical:USD 3 vs USD 10,P=0.004;indirect,time loss:USD 4 vs USD 13,P<0.001).The cost of the pre-treatment and intensive phases combined was also lower for direct medical(USD 15 vs USD 34,P=0.002)and non-medical(USD 30 vs USD 54,P=0.022)costs among ACF patients.The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds.A lower intensity of catastrophic costs was also documented for ACF patients,although the difference was not statistically significant.Conclusions:ACF can reduce patient-incurred costs substantially,contributing to the End TB Strategy target.Other synergistic policies,such as social protection,will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.

Assessment of the Indirect Cost of Drug Resistant Tuberculosis Treatment to Patients in a High Burden, Low Income Setting in Mozambique

Introduction: Tuberculosis is closely linked to poverty, with patients facing significant indirect treatment costs. Treating drug-resistant tuberculosis further increases these expenses. Notably, there is a lack of published data on the indirect costs incurred by patients with drug-resistant tuberculosis in Mozambique. Objective: To assess the indirect costs, income reduction, and work productivity incurred by patients undergoing diagnosis and treatment for Drug-Resistant Tuberculosis (DRTB) in Mozambique during their TB treatment. Methods: As part of a comprehensive mixed-methods study conducted from January 2021 to April 2023, this research utilized a descriptive cross-sectional approach, incorporating both quantitative and qualitative methods. The primary goal was to evaluate the costs incurred by the national health system due to drug-resistant TB. Additionally, to explore the indirect costs experienced by patients and their families during treatment, semi-structured interviews were conducted with 27 individuals who had been undergoing treatment for over six months. Results: All survey participants unanimously reported a significant decline in labour productivity, with 70.3% experiencing a reduction in their monthly income. Before falling ill, the majority of respondents (33.3%) earned up to $76.92 monthly, representing the minimum earnings range, while 29.2% had a monthly income above $230.77, the maximum earnings range. Among those who experienced income loss, the majority (22.2%) reported a decrease of up to $76.92 per month, and 18.5% cited a loss exceeding $230.77 per month. Notably, patients with Drug-Resistant Tuberculosis (DRTB) have not incurred the direct costs of the disease, as these are covered by the government. Conclusion: The financial burden of treating Drug-Resistant Tuberculosis (DRTB), along with the income reduction it causes, is substantial. Implementing a patient-centred, multidisciplinary, and multisector approach, coupled with strong psychosocial support, can significantly reduce the catastrophic costs DRTB patients incur.

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.

Costs incurred by patients with drugsusceptible pulmonary tuberculosis in semiurban and rural settings of Western India

Background:India reports the highest number of tuberculosis(TB)cases worldwide.Poverty has a dual impact as it increases the risk of TB and exposes the poor to economic hardship when they develop TB.Our objective was to estimate the costs incurred by patients with drug-susceptible TB in Bhavnagar(western India)using an adapted World Health Organization costing tool.Methods:We conducted a descriptive cross-sectional study of adults,notified in the public sector and being treated for drug-susceptible pulmonary TB during January-June 2019,in six urban and three rural blocks of Bhavnagar region,Gujarat state,India.The direct and indirect TB-related costs,as well as patients’coping strategies,were assessed for the overall care of TB till treatment completion.Catastrophic costs were defined as total costs>20%of annual household income(excluding any amount received from cash transfer programs or borrowed).Median and interquartile range(IQR)was used to summarize patient costs.The median costs between any two groups were compared using the median test.The association between any two categorical variables was tested by the Pearson chi-squared test.All costs were described in US dollars(USD).During the study period,on average,one USD equalled 70 Indian Rupees.Results:Of 458 patients included,70%were male,62%had no formal education,71%lived in urban areas,and 96%completed TB treatment.The median(IQR)total costs were USD 8(5-28),direct medical costs were USD 0(0-0),direct non-medical costs were USD 3(2-4)and indirect costs were USD 6(3-13).Among direct non-medical costs,travel cost(median=USD 3,IQR:2-4)to attend health facilities were the most prominent,whereas the indirect costs were mainly contributed by the patient’s loss of wages(median=USD 3,IQR:0-6).Four percent of patients faced catastrophic costs,11%borrowed money to cover costs and 7%lost their employment;the median working days lost to TB was 30(IQR:15-45).A majority(88%)of patients received a median USD 43(IQR:41-43)as part of a cash transfer program for TB patients.Conclusions:Treatment completion was high and the costs incurred by TB patients were low in this setting.However,negative financial consequences occur even in low-cost settings.The role of universal cash transfer programs in such settings requires further study.

Tuberculosis care strategies and their economic consequences for patients: the missing link to end tuberculosis

Background:While investment in the development of Tuberculosis(TB)treatment strategies is essential,it cannot be assumed that the strategies are affordable for TB patients living in countries with high economic constraints.This study aimed to determine the economic consequences of directly observed therapy for TB patients.Methods:A cross-sectional cost-of-illness analysis was conducted between September to November 2015 among 576 randomly selected adult TB patients who were on directly observed treatment in 27 public health facilities in Addis Ababa,Ethiopia.Data were collected using interviewer-administered questionnaire adapted from the Tool to Estimate Patients’Costs.Mean and median costs,reduction of productivity,and household expenditure of TB patients were calculated and ways of coping costs captured.Eta(η),Odds ratio and p values were used to measure association between variables.Results:Of the total 576 TB patients enrolled,43%were smear-positive pulmonary TB(PTB),17%smear-negative PTB,37%Extra-PTB and 3%multi-drug resistant TB cases.Direct(Out-of-Pocket)mean and median costs of TB illness to patients were$123.0(SD=58.8)and$125.78(R=338.12),respectively,and indirect(loss income)mean and median costs were$54.26(SD=43.5)and$44.61(R=215.6),respectively.Mean and median total cost of TB illness to patient were$177.3(SD=78.7)and$177.1(R=461.8),respectively.The total cost had significant association with patient’s household income,residence,need for additional food,and primary income(P<0.05).Direct costs were catastrophic for 63%of TB patients,regardless of significant difference between gender(P=0.92)and type of TB cases(P=0.37).TB patients mean productivity and income reduced by 37 and 10%,respectively,compared with pre-treatment level,while mean household expenditure increased by 33%and working hours reduced by 78%due to TB illness.Income quartile categories were directly correlated with catastrophic costs(η=0.684).Conclusion:Despite the availability of free-of-charge anti-TB drugs,TB patients were suffering from out-of-pocket payments with catastrophic consequences,which in turn were hampering the efforts to end TB.TB patients in resource-limited countries deserve integrated patient-centered care with comprehensive health insurance coverage,financial incentives,and nutrition support to reduce catastrophic costs and retain them in care.Such countries should induce home-based directly observed therapy programs to reduce costs due to attending health facilities,intensify home treatment of critically-ill patients with impaired mobility,and reduce the spread of TB due to patients traveling to seek care.