Association of Tuberculosis With Household Catastrophic Expenditure in South India

Abstract

IMPORTANCE The high household costs associated with tuberculosis (TB) diagnosis and treatment can create barriers to access and adherence, highlighting the urgency of achieving the World Health Organization's End TB Strategy target that no TB-affected households should face catastrophic costs by 2020.OBJECTIVE To estimate the occurrence of catastrophic costs associated with TB diagnosis and treatment and to identify socioeconomic indicators associated with catastrophic costs in a setting where TB control strategies have been implemented effectively. DESIGN, SETTING, AND PARTICIPANTSIn this cross-sectional study, 455 patients with TB in the Chennai metropolitan area of South India who were treated under the TB control program between February 2017 and March 2018 were interviewed. Patients were interviewed by trained field investigators at 3 time points: at the initiation of treatment, at the end of the intensive phase of treatment, and at the end of the continuation phase of treatment. A precoded interview schedule was used to collect information on demographic, socioeconomic, and clinical characteristics and direct medical, direct nonmedical, and indirect costs. Data analysis was performed from August 2018 to November 2019. MAIN OUTCOMES AND MEASURES Direct, indirect, and total costs to patients with TB.Catastrophic costs associated with TB were defined as costs exceeding 20% of the household's annual income. A binary response model was used to determine the factors that were significantly associated with catastrophic costs. RESULTSOf 455 patients with TB interviewed, 205 (53%) were aged 19 to 45 years (mean [SD] age, 38.4 [16.0] years), 128 (33%) were female, 72 (19%) were illiterate, 126 (33%) were employed, and 186 (48%) had a single earning member in the family (percentages are based on the 384 patients who were interviewed through the end of the continuation phase of treatment). Sixty-one percent of patients (234 patients) had pulmonary smear positive TB. The proportion of patients with catastrophic costs was 31%. Indirect costs contributed more toward catastrophic cost than did direct costs. Multivariate logistic regression analysis found that unemployment (adjusted odds ratio, 0.2; 95% CI, 0.1-0.5; P < .001) and higher annual household income (Rs 1-200 000, adjusted odds ratio, 0.4; 95% CI, 0.2-0.7; P = .004; Rs >200 000, adjusted odds ratio, 0.2; 95% CI, 0.1-0.5; P < .001) were associated with a decreased likelihood of experiencing catastrophic costs. CONCLUSIONS AND RELEVANCEDespite the implementation of free diagnostic and treatment services under a national TB control program, TB-affected households had a high risk of catastrophic (continued) Key Points Question What are the costs incurred by patients with tuberculosis (TB) throughout the treatment period in a resource-poor country such as India, where diagnostic testing and TB treatment are provided free of charge? Findings In this cross-sectional study of 455 individuals with TB, despite the implementation of free diagnostic and treatment services un...

Costs incurred by patients with drug-susceptible pulmonary tuberculosis in semi-urban and rural settings of Western India

“…The median costs reported in the present study were lower than those reported in most other studies from India [9,10,12,13,16,17,22,23]. The discrepancy might be because the current study estimated the costs among drug-susceptible pulmonary TB patients, whereas the published literature is inclusive of cost estimates on drug-resistant and extra-pulmonary TB patients.…”

“…Studies in India reported the percentage of catastrophic costs among drug-susceptible TB patients to be between 7 and 32% [9][10][11][12]. The average costs incurred by drug-susceptible TB patients treated in government health facilities are approximately USD 179, [9,10] whereas costs incurred by TB patients accessing care in all types of health facilities range from USD 20 to 224 [13][14][15][16][17].…”

“…In response to call for additional socioeconomic support for TB patients, the National TB Program (NTP) in India rolled out a direct benefit transfer (DBT) scheme in April 2018 with a credit of USD 7 (Indian Rupees [INR] 500) every month to support the nutritional requirements of TB patients [18]. However, only a few studies have assessed the complete costs incurred through treatment completion by TB patients in India using a validated WHO tool [9,11,12].…”

Factors associated with catastrophic total costs due to tuberculosis under a designated hospital service model: a cross-sectional study in China

“…In this study examining the catastrophic total costs due to TB among patients treated in the NTCP network under a designated hospital service model, we found that more than one-third of patients and their households who were diagnosed and treated in designated hospitals face financial disasters due to TB, especially those with MDR. The incidence of catastrophic costs in this survey is lower than those of Ghana [15] and Vietnam [16], and is similar to the results of studies in Indonesia [17], Peru [18], and southern India [19]. We identified several independent factors associated with catastrophic total costs in this study, these factors could have influenced healthcare costs through different mechanisms.…”

“…These findings highlighted that in addition to reducing the direct costs of TB care for patients, especially those with MDR and severe adverse drug reactions [15], other financial protection measures such as compensation for income losses were needed to prevent low-income households from incurring catastrophic costs following TB diagnosis [2,14,16]. Consistent with studies in other countries [17][18][19], there was an obviously negative correlation between the household's economic status and the occurrence of catastrophic total costs, that is, financially vulnerable households were more likely to suffer catastrophic costs. This prompted us to think about the drawbacks of the balanced subsidy policy.…”