Catastrophic costs among tuberculosis patients in Zimbabwe: a national health facility-based survey

Abstract

Background: Tuberculosis (TB) has biological and socio-economic dimensions. The socio-economic impact of TB may plunge households into financial catastrophes. The End TB strategy seeks to mitigate socio-economic factors which may act as barriers to accessing TB services. Countries have been encouraged to provide baseline estimates of catastrophic costs by 2020. We sought to determine the prevalence, risk factors and major drivers of catastrophic costs among TB patients in Zimbabwe. Methods: We conducted a nationally representative, health facility-based survey with random cluster sampling among TB patients. We enrolled patients with drug susceptible (DS-TB) and drug resistant TB (DR-TB) consecutively. We administered a standardised questionnaire to capture the costs incurred as well as lost income due to TB illness. Catastrophic costs were measured at a threshold of 20%. We did a sensitivity analysis of indirect costs using the time lost by patients in each phase of treatment. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs. Results: A total of 841 patients were enrolled in the survey, weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI:77-82%) of TB patients and their households experienced catastrophic costs. The major cost drivers pre-TB diagnosis were direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, (median cost US$360 (IQR: 240-600). Post-TB diagnosis costs were three-times higher among DR-TB [US$1,659 (653-2,787)] versus drug susceptible TB (DS-TB) affected households [US$537 (204-1,134)]. Income loss was five-times higher among DR-TB versus DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: the poorest households had sixteen times the odds of incurring catastrophic costs compared to wealthiest households [adjusted odds ratio (aOR:15.7 95% CI:7.5-33.1)]. Conclusion: The majority of TB patients enrolled in care experienced catastrophic costs, with the highest burden on DR-TB patients. Since the major cost drivers fall outside the healthcare system, a multi-sectoral approach to TB control and linking TB patients to social protection schemes holds promise for reducing catastrophic costs in Zimbabwe.

A Systematic Review and Meta-Analysis on Catastrophic Cost Incurred by Tuberculosis Patients

“…was not calculated as the heterogeneity was high. The proportion was variants, two studies reported similar proportions, Tomeny, 2020 [15] & Collins Timire, 2020 [47] with a proportion of 41% and 43% respectively. However, higher proportion 52% reported among Chittamany2020 [33] and Nhung, 2018 [37].…”

“…The proportion of the mean direct cost to the mean total cost at 20% addressed in 7 studies, ranged from 26% in Chittamany, 2020 [33] to 93% in Yang, 2020 [32]. Low proportions were observed in Fuady, 2018 [41], Tomeny, 2020 [15], and Collins Timire, 2020 [47] with proportion of 32%, 34% and 49% respectively, while high proportion also reported in Muttamba, 2020 [30], with 66% and in Nhung, 2018 [37] with 68%. The pooled proportion of mean direct to total cost was di cult to assess because of the heterogeneity which wasn't explained even after a meta-regression performed.…”

“…The direct cost including medical and non-medical cost represented 51%, 95%CI[43-59%] of the total cost. Among drug sensitive and drug resistant TB, the proportion of direct cost to the total cost ranged from (33-65%)[15,30,33,37,41,47] and (26%-93%)[15,30,32,33,37,41,47] respectively. ACF incurred lower catastrophic than PCF 29%, 95%C1[20-41%] versus 37%, 95%C1[34-40%].…”

A Systematic Review and Meta-Analysis on Catastrophic Cost incurred by Tuberculosis Patients and their Households

“…2018 [41], Tomeny, 2020 [15], and Collins Timire, 2020 [47] with proportion of 32%, 34% and 49% respectively, while high proportion also reported in Muttamba, 2020 [30], with 66% and in Nhung, 2018 [37] with 68%. The pooled proportion of direct to total cost was difficult to assess because of the heterogeneity which wasn't explained even after a meta-regression performed.…”

“…With 63% pooled proportion, 95%CI [40-80%], I 2 = 96%, three studies measured the CTP at 40% [12,29,30] and after the sensitivity test the heterogeneity was I 2= 0, while the pooled proportion increased to 70%, 95%CI [64-76%]. Among drug sensitive and drug resistant TB, the proportion of direct cost to the total cost ranged from (33% to 65%) [15,30,33,37,41,47] and (26%-93%) [15,30,32,33,37,41,47] respectively.…”