Mitigating Financial Burden of Tuberculosis through Active Case Finding Targeting Household and Neighbourhood Contacts in Cambodia

Abstract

BackgroundDespite free TB services available in public health facilities, TB patients often face severe financial burden due to TB. WHO set a new global target that no TB-affected families experience catastrophic costs due to TB. To monitor the progress and strategize the optimal approach to achieve the target, there is a great need to assess baseline cost data, explore potential proxy indicators for catastrophic costs, and understand what intervention mitigates financial burden. In Cambodia, nationwide active case finding (ACF) targeting household and neighbourhood contacts was implemented alongside routine passive case finding (PCF). We analyzed household cost data from ACF and PCF to determine the financial benefit of ACF, update the baseline cost data, and explore whether any dissaving patterns can be a proxy for catastrophic costs in Cambodia.MethodsIn this cross-sectional comparative study, structured interviews were carried out with 108 ACF patients and 100 PCF patients. Direct and indirect costs, costs before and during treatment, costs as percentage of annual household income and dissaving patterns were compared between the two groups.ResultsThe median total costs were lower by 17% in ACF than in PCF ($240.7 [IQR 65.5–594.6] vs $290.5 [IQR 113.6–813.4], p = 0.104). The median costs before treatment were significantly lower in ACF than in PCF ($5.1 [IQR 1.5–25.8] vs $22.4 [IQR 4.4–70.8], p<0.001). Indirect costs constituted the largest portion of total costs (72.3% in ACF and 61.5% in PCF). Total costs were equivalent to 11.3% and 18.6% of annual household income in ACF and PCF, respectively. ACF patients were less likely to dissave to afford TB-related expenses. Costs as percentage of annual household income were significantly associated with an occurrence of selling property (p = 0.02 for ACF, p = 0.005 for PCF).ConclusionsTB-affected households face severe financial hardship in Cambodia. ACF has the great potential to mitigate the costs incurred particularly before treatment. Social protection schemes that can replace lost income are critically needed to compensate for the most devastating costs in TB. An occurrence of selling household property can be a useful proxy for catastrophic cost in Cambodia.

Active case finding among marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis diagnosis

“…The comparison group included patients from the same month and from the marginalised/vulnerable populations of the same area as the Axshya SAMVAD patients. Second, similar to Mauch et al and Morishita et al [11,23], we included a nationally representative sample, the reference population for which was limited to the Axshya districts ( n  = 285). The findings are also representative of their respective reference populations with potential contaminated exposures excluded.…”

“…This could be because of the low sample size (around 100 in each arm) and lack of a confounder-adjusted analysis. However, they did not provide catastrophic costs due to the TB diagnosis [23]. …”

“…The effect of ACF on inequity in distribution of catastrophic costs was also not assessed [23]. Although there have been studies on patient costs due to TB care in India [24], studies on catastrophic costs are limited.…”

Drop-out from the tuberculosis contact investigation cascade in a routine public health setting in urban Uganda: A prospective, multi-center study

“…[12][13][14][15][16][17] To improve delivery of contact investigation and other active case-finding strategies, there is a need for attention to each step in the process to avoid excessive cumulative losses. We applied a cascade analysis to identify the greatest gaps in delivery of household contact investigation and follow-up evaluation in a programmatic setting.…”

Uptake of home-initiated tuberculosis evaluation during household contact investigation in Kampala, Uganda: A mixed-methods study

“…[1][2][3][4][5] One important tool for active case-finding is household contact investigation. 6 However, case-finding through contact investigation depends on contacts' ability and willingness not only to complete screening for TB symptoms and risk factors, but also to complete TB evaluation if referred.…”