Estimating the pre- and post-diagnosis costs of tuberculosis for adults in Pakistan: household economic impact and costs mitigating strategies

Abstract

Background Despite free tuberculosis (TB) care in Pakistan, patients still have to bear high costs, which push them into poverty. This study estimated the pre- and post-diagnosis costs households bear for TB care, and investigated coping mechanisms among adults ≥ 18 years in Karachi, Pakistan. Methods We conducted a cross-sectional study comprising of 516 TB patients identified with completion of at least one month intensive treatment from four public sector health facilities from two institutes in Karachi, Pakistan. A standardized questionnaire to estimate patient's costs was administered. The study outcomes were direct medical and non-medical costs, and indirect costs. The costs were estimated during pre-diagnostic and post-diagnostic phase which includes diagnostic, treatment, and hospitalization phases. A descriptive analysis including mean and standard deviation (± SD), median and interquartile range (IQR), and frequencies and proportions (%) was employed. Results Out of 516 TB patients, 52.1% were female with a mean age of 32.4 (± 13.7) years. The median costs per patient during the pre-diagnostic, diagnostic, treatment and hospitalization periods were estimated at USD63.8/ PKR7,377, USD24/ PKR2,755, USD10.5/ PKR1,217, and USD349.0/ PKR40,300, respectively. The total household median cost was estimated at USD129.2/ PKR14,919 per patient. The median indirect cost was estimated at USD52.0/ PKR5,950 per patient. Of total, 54.1% of patients preferred and consulted private providers in the first place at the onset of symptoms, while, 36% attended public healthcare services, 5% and 4.1% went to dispensary and pharmacy, respectively, as a first point of care. Conclusions TB patients bear substantial out-of-pocket costs before they are enrolled in publically funded TB programs. There should be provision of transport and food vouchers, also health insurance for in-patient treatment. This advocates a critical investigation into an existing financial support network for TB patients in Pakistan towards reducing the burden.

“Post-tuberculosis financial disease”—we need to face it to eliminate tuberculosis

“…The authors also identified an overall average cost of R$283.84 during the pre-diagnosis period and of R$4,161.86 during the post-diagnosis period, which involved not only the patients but also their households. 1 In contrast to previous studies, 4 post-tuberculosis costs were almost 15 times higher than were pre-tuberculosis costs, and that was mostly attributed to non-medical direct and indirect costs, including loss of income in 60% of cases.…”

“…However, most studies regarding financial issues related to tuberculosis address costs during pre-diagnosis, diagnosis, and treatment, leaving aside post-disease losses. 3 , 4 …”

Assessing the influencing factors of out-of-pocket costs on tuberculosis in Sichuan Province: a cross-sectional study

“…During a patient's hospital stay, the cost of food and accommodation for the caregiver significantly increases, along with the indirect cost of the caregiver's absence from the work. Patients with a history of hospitalization also had higher medical and family care costs [ 37 ]. In addition, a hospitalized patient had a more severe condition, so the indirect costs increased accordingly.…”

Better understanding extrapulmonary tuberculosis: A scoping review of public health impact in Pakistan, Afghanistan, India, and Bangladesh

“…The out‐of‐pocket healthcare expenditure can be significant for TB taking into consideration factors such as the need to sometimes buy the antibiotics and the long duration of treatment. A study by Razzaq et al estimated the pre‐ and post‐diagnosis cost of TB which came out to be 63.8 USD pre‐diagnosis, 24 USD after diagnosis, 10.5 USD for treatment, and 349 USD for hospitalization 39 . Moreover, according to a cross‐sectional survey in 2020, the median cost of TB in Pakistan was found to be approximately 360 USD and around 67% of patient's households were affected by the catastrophic costs, especially if the patient is the sole bread earner of the house as the treatment led to unpaid sick leaves and even loss of job 40 .…”

“…27 USD for treatment, and 349 USD for hospitalization. 39 Moreover, according to a cross-sectional survey in 2020, the median cost of TB in Pakistan was found to be approximately 360 USD and around 67% of patient's households were affected by the catastrophic costs, especially if the patient is the sole bread earner of the house as the treatment led to unpaid sick leaves and even loss of job. 40…”