Determinants of catastrophic costs among households affected by multi-drug resistant tuberculosis in Ho Chi Minh City, Viet Nam: a prospective cohort study

Abstract

Background Globally, most people with multidrug-resistant tuberculosis (MDR-TB) and their households experience catastrophic costs of illness, diagnosis, and care. However, the factors associated with experiencing catastrophic costs are poorly understood. This study aimed to identify risk factors associated with catastrophic costs incurrence among MDR-TB-affected households in Ho Chi Minh City (HCMC), Viet Nam. Methods Between October 2020 and April 2022, data were collected using a locally-adapted, longitudinal WHO TB Patient Cost Survey in ten districts of HCMC. Ninety-four people with MDR-TB being treated with a nine-month TB regimen were surveyed at three time points: after two weeks of treatment initiation, completion of the intensive phase and the end of the treatment (approximately five and 10 months post-treatment initiation respectively). The catastrophic costs threshold was defined as total TB-related costs exceeding 20% of annual pre-TB household income. Logistic regression was used to identify variables associated with experiencing catastrophic costs. A sensitivity analysis examined the prevalence of catastrophic costs using alternative thresholds and cost estimation approaches. Results Most participants (81/93 [87%]) experienced catastrophic costs despite the majority 86/93 (93%) receiving economic support through existing social protection schemes. Among participant households experiencing and not experiencing catastrophic costs, median household income was similar before MDR-TB treatment. However, by the end of MDR-TB treatment, median household income was lower (258 [IQR: 0–516] USD vs. 656 [IQR: 462–989] USD; p = 0.003), and median income loss was higher (2838 [IQR: 1548–5418] USD vs. 301 [IQR: 0–824] USD; p < 0.001) amongst the participant households who experienced catastrophic costs. Being the household’s primary income earner before MDR-TB treatment (aOR = 11.2 [95% CI: 1.6–80.5]), having a lower educational level (aOR = 22.3 [95% CI: 1.5–344.1]) and becoming unemployed at the beginning of MDR-TB treatment (aOR = 35.6 [95% CI: 2.7–470.3]) were associated with experiencing catastrophic costs. Conclusion Despite good social protection coverage, most people with MDR-TB in HCMC experienced catastrophic costs. Incurrence of catastrophic costs was independently associated with being the household’s primary income earner or being unemployed. Revision and expansion of strategies to mitigate TB-related catastrophic costs, in particular avoiding unemployment and income loss, are urgently required.

Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance

“…This rate is lower than other recent SHI coverage reports. A 2018–2022 DS-TB costing survey reported a SHI coverage of 70% [ 32 ], while in a DR-TB costing survey (2020–2022) it was 85% [ 16 ]. All available data sources indicate that SHI coverage among people with TB is lower than the general population, which is indicative of their socioeconomic vulnerability [ 33 ].…”

“…A national costing survey of TB-affected households showed that 63% experienced catastrophic costs, spending ≥ 20% of their annual income on TB [ 10 ]. Many face food insecurity and cope with TB-related costs by taking loans, dissavings and informally borrowing money [ 10 , 15 , 16 ].…”