Abstract
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. 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. In 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. 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. Of 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. Despite the implementation of free diagnostic and treatment services under a national TB control program, TB-affected households had a high risk of catastrophic costs and further impoverishment. There is an urgent demand to provide additional financial protection for patients with TB.
Highlights
India’s National Strategic Plan for Tuberculosis elimination aims to achieve the goal of ending tuberculosis (TB) by 2025, well ahead of the global deadline of 2035.1 One of the key aspects of TB burden in India is the extreme poverty often associated with this disease.[2,3] In spite of the free-ofcharge TB diagnostic and treatment services, patients with TB may become trapped in poverty.[4,5] Extreme levels of socioeconomic difficulty experienced by patients with TB necessitate increased attention toward the World Health Organization’s target of 0 TB-affected families facing catastrophic TB-related costs.[6]
Multivariate logistic regression analysis found that unemployment 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
Chennai is one of the most urbanized metropolitan areas in India, with a population of 8 653 521, including approximately 7000 patients with TB who are treated every year under the Revised National Tuberculosis Control Programme (RNTCP).[12]
Summary
India’s National Strategic Plan for Tuberculosis elimination aims to achieve the goal of ending tuberculosis (TB) by 2025, well ahead of the global deadline of 2035.1 One of the key aspects of TB burden in India is the extreme poverty often associated with this disease.[2,3] In spite of the free-ofcharge TB diagnostic and treatment services, patients with TB may become trapped in poverty.[4,5] Extreme levels of socioeconomic difficulty experienced by patients with TB necessitate increased attention toward the World Health Organization’s target of 0 TB-affected families facing catastrophic TB-related costs.[6]. Chennai is one of the most urbanized metropolitan areas in India, with a population of 8 653 521, including approximately 7000 patients with TB who are treated every year under the Revised National Tuberculosis Control Programme (RNTCP).[12] A prevalence study[13] conducted during 2010 to 2012 found a TB prevalence rate in Chennai of 259 cases per 100 000, which was higher than the prevalence rates in other parts of the country (207 cases per 100 000). Forty percent of the Chennai population live in slums, are socioeconomically disadvantaged, and have a higher burden of TB compared with nonslum dwellers.[7] Studies[14] concerning out-of-pocket expenditures and loss of income associated with TB were conducted in Chennai in 1997, but since there has been a paucity of evidence about the magnitude of the economic burden associated with TB
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