Implementation research studies supported by TDR’s Impact Grants for Regional Priorities explored the root causes of catastrophic costs of tuberculosis (TB) treatment for households in several countries. The grants supported researchers in Afghanistan, Egypt, Iran, Malaysia, Mongolia, Pakistan, Philippines, the Republic of Moldova, Viet Nam and Yemen. The studies highlight actions that public health policy-makers can take to increase treatment adherence and reduce the financial impact on families.
A health worker at a tuberculosis health service in Ulaanbaatar, Mongolia, orients TB patients
Credit: WHO / K. Sandag
In addition to the burden that TB puts on millions of people suffering from the disease, many families and households in low-income countries are affected by another burden – the catastrophic cost of treatment and continuing care. (Catastrophic cost is defined as a financial burden above 20% of the household income due to the condition.)
One of the targets of WHO’s End TB Strategy is that no TB patient or their household experiences catastrophic costs due to TB. While the cost of medicine is typically covered by the health system, patients face a range of other recurring costs including the costs of accommodation, transport to healthcare facilities and consultations, multivitamins, and loss of income due to missed work opportunities. The average expenditure incurred by patients in low- and middle-income countries (LMICs) for the diagnosis and treatment of TB ranges from US$ 55 to US$ 8198. The upper end of this range can lead to the impoverishment of households.
Some highlights from the ten studies are shared below:
Pakistan: Revealing the full cost of TB treatment
A study by Pakistan’s National Institutes of Health was the first of its kind in the country to identify the factors that cause catastrophic TB care costs. Based on the findings, the team calls on public health policy-makers to put in place healthcare interventions that provide social protection to patients and their guardians that go beyond providing free TB drugs, diagnostic tests, and nutritional supplements. They must address the stigma associated with the disease, which plays an important role in income loss, and is the driving force behind social exclusion. The study referred to previous assessments in Indonesia. The researchers say that their findings can inform public health strategies in countries with similar public health structures, such as India and Bangladesh. Read the full interview with one of the researchers.
Egypt, Mongolia and the Republic of Moldova: quantifying the scope of TB household costs
Socioeconomic studies focused on the processes and policies needed for a clear assessment of TB household costs so that public health services can respond effectively. The Moldova study revealed that catastrophic cost levels were experienced by 23% of the households surveyed. Indirect costs averaged 70% of patients’ income for multidrug-resistant treatments; direct costs were 17% of total household income. Incentives provided during outpatient treatment gave some help to affected households to contain TB-associated costs.
Viet Nam: Identifying the main drivers of high TB costs
A research team in Viet Nam identified the main drivers of high TB costs and looked at mitigation policies to alleviate financial struggles for TB-affected households, especially in lower-income communities. Their assessment found that a lack of access to diagnosis is a critical barrier that threatens patients’ ability to complete treatment. Social support mechanisms for TB-affected households were also assessed by the research team.
Philippines: Training nurses and interviewers to improve statistical analysis
This study in the Philippines used the WHO Catastrophic Costs tool to improve data collection. During the study, nurses and interviewers were given training so as to improve statistical analysis and thereby better identify households that face financial distress.
Malaysia: A smartphone application for rapid assessment of the TB financial burden on communities
This study created a smartphone application (app) to streamline follow-up between medical staff and TB patients. This new tool brings a dual benefit to public health managers and community organizations: a more precise view of the financial burden of TB in their communities as well as reduced indirect costs tied to frequent travel and accommodation (near medical centres).
The Impact Grants for Regional Priorities support researchers and public health practitioners as part of TDR’s collaboration with WHO regional offices. The objective is to produce implementation research findings that can help build national strategies and action plans for better control and treatment of infectious diseases of poverty.
PROJECTS FUNDED BY TDR’S IMPACT GRANTS FOR REGIONAL PRIORITIES
Assessing household catastrophic total cost of tuberculosis and their determinants in Egypt: A cohort prospective study
Mohsen GADALLAH
Faculty of Medicine, Ain Shams University, Ministry of Health and Population, Cairo
EGYPT
Survey estimating direct and indirect costs due to tuberculosis and proportion of tuberculosis-affected households experiencing catastrophic costs due to TB in Alexandria
Mohsen GADALLAH
Faculty of Medicine, Ain Shams University, Ministry of Health and Population, Cairo
EGYPT
Measuring the catastrophic cost of diagnosis, treatment, care and support on people and families affected by tuberculosis in Iran and Afghanistan
Social Determinants of Health Research Center, Guilan University of Medical Sciences, Rasht
IRAN/AFGHANISTAN
Implementation and economic evaluation of gamified mobile apps tool for improved treatment adherence among working-aged TB patients in Malaysia
Nurhuda ISMAIL
Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA
MALAYSIA
Assessing catastrophic expenses of families/households associated with treatment resistant TB (MDR-TB) in the Republic of Moldova
Anna CIOBANU
National TB Control Programme
REPUBLIC OF MOLDOVA
Assessing the financial burden of tuberculosis for patients in Mongolia
Dr Nasanjargal PUREV
National Center for Communicable Diseases, Ulaanbaatar
MONGOLIA
Financial burden of multi-drug resistant tuberculosis on patients attending the PMDT sites in Pakistan
The Solution Pvt|
PAKISTAN
Is tuberculosis treatment truly free? A study to identify key factors contributing towards the catastrophic cost of TB care in Pakistan
Dr Aamer IKRAM
Establishment of Environmental Health, National Institutes of Health, Islamabad
PAKISTAN
Assessing TB patient costs and treatment adherence in the Philippines by longitudinal data collection
Mary Christine CASTRO
Nutrition Center of the Philippines, Manila
PHILIPPINES
Determining direct and indirect costs due to tuberculosis and to estimate proportion of TB-affected households experiencing catastrophic costs in Vietnam
Nhung NGUYEN
Vietnam National Tuberculosis Program, National Lung Hospital
VIET NAM
Yemen: Multi-center estimation of the catastrophic costs associated with tuberculosis diagnosis and treatment in Yemen in the context of conflict. How can we mitigate the costs of treatment for TB?
University of Science and Technology, Sana’a
YEMEN
For more information on the Impact Grants programme, please contact Dr Garry Aslanyan.