6.2 National surveys of costs faced by TB patients and their households
The World Health Organization (WHO) End TB Strategy includes the target that no tuberculosis (TB) patients and their households face catastrophic total costs because of TB disease. Total costs are defined as the sum of direct medical expenditures, direct nonmedical expenditures and indirect costs (e.g. income losses). This target was set because everyone who develops TB disease needs to be able to access diagnosis and treatment, and if this is not ensured the End TB Strategy targets for reductions in TB disease burden (incidence and mortality) will not be achieved.
WHO has established standard methods for conducting a national survey to assess the direct and indirect costs incurred by people with TB and their households (TB patient cost surveys) (1). Since 2015, there has been substantial progress in the planning and implementation of national TB patient cost surveys (Fig. 6.2.1).
Fig. 6.2.1 National surveys of costs faced by TB patients and their households since 2015: progress and plans (as of September 2022)
By September 2022, 29 countries had completed a survey (Fig. 6.2.2).
Fig. 6.2.2 Timeline of national TB patient cost surveys implemented since 2015 (as of September 2022)
In the 27 surveys for which results have been reported, the percentage of TB patients and their households that experienced catastrophic total costs (defined as >20% of household expenditure or income) ranged from 13% (95% confidence interval
[CI]: 10–17%) in El Salvador to 92% (95% CI: 86–97%) in Solomon Islands (Fig. 6.2.3). The pooled average for all 27 countries, weighted for each country’s
number of notified cases, was 48% (95% CI: 36–61%). Among 23 countries that reported disaggregated data, the percentage facing catastrophic total costs was much higher for people with drug-resistant TB (DR-TB), with a pooled average of 82%
(95% CI: 75–90%).
Fig. 6.2.3 Estimates of the percentage of TB patients and their households facing catastrophic costs,a national surveys completed 2016–2022
a Defined as direct medical expenditures, direct nonmedical expenditures and indirect costs (e.g. income losses) that sum to >20% of household income. This indicator is not the same as the SDG indicator for catastrophic health expenditures.
b Disaggregated estimates for TB (first-line treatment) and drug-resistant TB were available for only 23 countries. The calculation of confidence intervals for Mali and Uganda did not account for sampling design.
c Since 95% confidence intervals were not included in the national survey report, simple binomial confidence intervals were calculated based on the survey sample size.
Source: WHO Global TB Programme
The distribution of costs faced by TB patients and their households varies among countries (Fig. 6.2.4). However, it was evident that – despite the widespread norm
of “free TB care” policies – TB-affected households still face direct medical costs. Such costs accounted for a sizeable proportion of total costs in some countries (e.g. Mali). Minimizing direct medical costs borne by TB
patients should be a high priority for national TB programmes (NTPs) and ministries of health.
Fig. 6.2.4 Distribution of costs faced by TB patients and their households in national surveysa completed 2016–2022
Source: WHO Global TB Programme
The surveys also showed that actions are needed to eliminate direct nonmedical costs and to reduce indirect costs. The combined cost of transportation, food, nutritional supplements and other nonmedical expenditures (“direct nonmedical
costs”) accounted for a substantial share (50% or more) of total costs in some countries, including Colombia, El Salvador, Fiji, Kenya, Mali, Solomon Islands, Timor-Leste, Uganda and the United Republic of Tanzania. Indirect costs associated
with loss of employment or time lost while seeking or staying in care accounted for the largest single share of total costs in Brazil, Burkina Faso, Indonesia, Lesotho, Mongolia, Myanmar, Nigeria, Papua New Guinea, South Africa, Viet Nam and Zimbabwe.
All cost categories are influenced by the model of TB care; for example, to what extent there is reliance on hospitalization or outpatient care, the frequency with which attendance at health facilities is requested and the level to which services are decentralized to bring the services close to the community. They are also influenced by ease of access to the health facilities used to provide care.
Social protection is required to mitigate or eliminate direct nonmedical costs and indirect costs. Only 16 of the 30 high TB burden countries have a national policy that is specifically related to social protection for people with TB (Table 6.2.1). Free access to medical services is the most commonly-used measure (15/16 countries); at least one other form of social protection (such as cash transfers, enablers to adhere to treatment, support to help with food security) is provided in 14 countries.
Table 6.2.1 Status of social protection for people with TB, 30 high TB burden countries
Comprehensive documentation about the 20 national surveys completed between 2015 and 2021 that used WHO-recommended methods and for which results have been shared with WHO are available in a book published by WHO in 2022 (2). This includes cross-cutting chapters on methods, results, policy implications and future direction, and profiles for each national survey in a standardized format.
Note: The distribution of costs faced by TB patients and their households in Colombia shown in figure 6.2.4 was updated on 2 December 2022 after fixing a data encoding error.
References
Tuberculosis patient cost surveys: a handbook. Geneva: World Health Organization; 2017 (https://www.who.int/publications/i/item/9789241513524).
National surveys of costs faced by TB patients and their households, 2015–2021. Geneva: World Health Organization; in press.