Cost of Tuberculosis Care in Programmatic Settings from Karnataka, India: Is It Catastrophic for the Patients?

Abstract

Background. TB diagnostic and treatment services in India are provided free of cost in the programmatic context across the country. There are different costs incurred during health care utilization, and this study was conducted to estimate such costs. Methodology. A longitudinal study was conducted among patients of three urban tuberculosis units (TUs) of Davangere, Belagavi, and Bengaluru, Karnataka. Trained data collectors administered a validated questionnaire and recorded monthly costs incurred by the patients which are expressed in median Indian National Rupees (INR). The analysis was done using SPSS version 23.0. A p value of <0.05 was taken as statistically significant. Results. Among 214 patients, about 37%, 42%, and 21% belonged to Davangere, Belagavi, and Bengaluru, respectively. Median total pre- and postdiagnostic costs incurred across the three TUs were 3800 and 4000 INR, respectively. The direct nonmedical cost was higher for accommodation (median cost of 800 INR) and direct medical cost for non-TB drugs (median cost of 2000 INR). However, maximum direct medical and nonmedical costs were attributed to hospital admissions (1200 INR) and accommodation costs (700 INR) in the postdiagnostic period, respectively. The median indirect cost incurred was 300 INR overall, and the maximum total indirect cost was 40000 INR in the postdiagnostic period. About one-third of patients faced loss of income and 19.6% faced coping costs. Patients spent about 6.7% (0.97%–52.3%) of their income on TB treatment. About 12.3% patients faced catastrophic expenditure. Median cost was significantly higher among those seeking private health care facilities (12100 INR in private vs. 6800 INR in public; p<0.05) during the prediagnostic period. Prediagnostic and diagnostic out-of-pocket expenditures (OPE) were significantly higher across all the three centres (p<0.05). Conclusion. The TB patients experienced untoward expenditure under programmatic settings. The costs encountered by one in eight patients were catastrophic by nature.

Rising healthcare expenditure on tuberculosis: Can India achieve the End TB goal?

“…This is highly discouraging given the strengthening of the health systems under the National TB Elimination Strategy; however, there is a need for further studies to confirm this. Previous studies in India have reported significant OOPE and catastrophic impact on households due to TB [18][19][20][21][22][23][24]. However, the results from these studies are not comparable to our study due to varying definitions of catastrophic health expenditure, the included costs (in some of these studies only direct costs were included, others included indirect costs as well) and the thresholds for considering costs as catastrophic [38,47,48].…”

“…There is also a need to consider the amount transferred under DBT as it would not be sufficient enough as compensation to manage the financial burden of TB of most patients [22]. There is also high utilisation of private hospitals for TB treatment over the last decade as evident from our analysis and other studies [22]. There is a need for improved working and collaboration of private health facilities to provide TB care; one such model that seems to work is in Mehsana, Gujarat state [49].…”

“…Most studies in India focusing on healthcare expenditure on TB are limited to a specific geographical area, or tribal populations, and mainly included patients enrolled in the National TB Program for treatment [18][19][20][21][22][23][24]. Two studies have used nationally representative surveys conducted by the National Sample Survey (NSS) on household expenditure patterns [17,25].…”

Rising Catastrophic Expenditure on Households Due to Tuberculosis: Is India Moving Away From the END-TB Goal?

“…This is encouraging and could be attributed to the various scheme and health system strengthening under the National TB Elimination Program (NTEP), although further studies are required to confirm this. Previous studies in India, China, Peru, and few African countries have also reported significant cost of care and impact on households due to TB care ( 3 , 7 – 9 , 13 – 17 ). A recent cross-sectional study of 455 individuals with TB in South India showed that despite the implementation of free diagnostic and treatment services under a national TB control program, one-third of TB-affected households still experienced catastrophic costs ( 18 ).…”

“…A similar cross-sectional study among 450 TB patients in New Delhi, India reported that 7% of patients registered under the national TB program experienced catastrophic expenditure, with a large proportion being accounted by indirect costs ( 19 ). Poornima et al also reported significant cost of care due to TB in programmatic settings with one in eight patients experiencing catastrophic expenditure ( 17 ). A direct comparison of the figures in these studies would not be fair as they involved different cut-offs of catastrophic expenditure, varying periods of follow-up and different methodologies.…”