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 patientsCredit: 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 treatmentA 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 costsA 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 studyMohsen GADALLAHFaculty of Medicine, Ain Shams University, Ministry of Health and Population, CairoEGYPTSurvey estimating direct and indirect costs due to tuberculosis and proportion of tuberculosis-affected households experiencing catastrophic costs due to TB in AlexandriaMohsen GADALLAHFaculty of Medicine, Ain Shams University, Ministry of Health and Population, CairoEGYPT

Measuring the catastrophic cost of diagnosis, treatment, care and support on people and families affected by tuberculosis in Iran and AfghanistanSocial Determinants of Health Research Center, Guilan University of Medical Sciences, RashtIRAN/AFGHANISTAN

Implementation and economic evaluation of gamified mobile apps tool for improved treatment adherence among working-aged TB patients in MalaysiaNurhuda 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 MoldovaAnna CIOBANU National TB Control Programme REPUBLIC OF MOLDOVA

Assessing the financial burden of tuberculosis for patients in MongoliaDr Nasanjargal PUREV National Center for Communicable Diseases, UlaanbaatarMONGOLIA

Financial burden of multi-drug resistant tuberculosis on patients attending the PMDT sites in PakistanThe 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, IslamabadPAKISTAN

Assessing TB patient costs and treatment adherence in the Philippines by longitudinal data collectionMary Christine CASTRO Nutrition Center of the Philippines, ManilaPHILIPPINESDetermining direct and indirect costs due to tuberculosis and to estimate proportion of TB-affected households experiencing catastrophic costs in VietnamNhung NGUYEN Vietnam National Tuberculosis Program, National Lung HospitalVIET 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’aYEMEN

For more information on the Impact Grants programme, please contact Dr Garry Aslanyan.