Tuberculosis and poverty: the contribution of patient costs in sub-Saharan Africa – a systematic review

Abstract

BackgroundTuberculosis (TB) is known to disproportionately affect the most economically disadvantaged strata of society. Many studies have assessed the association between poverty and TB, but only a few have assessed the direct financial burden TB treatment and care can place on households. Patient costs can be particularly burdensome for TB-affected households in sub-Saharan Africa where poverty levels are high; these costs include the direct costs of medical and non-medical expenditures and the indirect costs of time utilizing healthcare or lost wages. In order to comprehensively assess the existing evidence on the costs that TB patients incur, we undertook a systematic review of the literature.MethodsPubMed, EMBASE, Science Citation Index, Social Science Citation Index, EconLit, Dissertation Abstracts, CINAHL, and Sociological Abstracts databases were searched, and 5,114 articles were identified. Articles were included in the final review if they contained a quantitative measure of direct or indirect patient costs for treatment or care for pulmonary TB in sub-Saharan Africa and were published from January 1, 1994 to Dec 31, 2010. Cost data were extracted from each study and converted to 2010 international dollars (I$).ResultsThirty articles met all of the inclusion criteria. Twenty-one studies reported both direct and indirect costs; eight studies reported only direct costs; and one study reported only indirect costs. Depending on type of costs, costs varied from less than I$1 to almost I$600 or from a small fraction of mean monthly income for average annual income earners to over 10 times average annual income for income earners in the income-poorest 20% of the population. Out of the eleven types of TB patient costs identified in this review, the costs for hospitalization, medication, transportation, and care in the private sector were largest.ConclusionTB patients and households in sub-Saharan Africa often incurred high costs when utilizing TB treatment and care, both within and outside of Directly Observed Therapy Short-course (DOTS) programs. For many households, TB treatment and care-related costs were considered to be catastrophic because the patient costs incurred commonly amounted to 10% or more of per capita incomes in the countries where the primary studies included in this review were conducted. Our results suggest that policies to decrease direct and indirect TB patient costs are urgently needed to prevent poverty due to TB treatment and care for those affected by the disease.

Household Catastrophic Health Expenditure Due To Tuberculosis: Analysis From Particularly Vulnerable Tribal Group, Central India

“…10% of annual family income. Our study finding corroborate with the study done in Malawi and Kenya which reported that patient and household costs of TB diagnosis are prohibitively high where services are provided free of charge [22,30,31]. In tribal areas mostly travel facilities are poor and health centres are not always easily accessible due to this.…”

Defining Catastrophic Costs and Comparing Their Importance for Adverse Tuberculosis Outcome with Multi-Drug Resistance: A Prospective Cohort Study, Peru

“…As in previous studies [8],[9],[11], poorer people incurred the most catastrophic costs, which they were less able to afford, probably causing further impoverishment [7],[44]. In agreement with other findings, our results indicate that costs as a proportion of the same household's income indicate economic challenge better than actual monetary expenditures: this finding highlights the “medical poverty trap”, that as incomes decrease, proportional costs increase [6],[45].…”

Catastrophic costs of tuberculosis care: a mixed methods study from Puducherry, India

“…In our study, with 45% of the patients having been hospitalized at some point during diagnosis and treatment, this is a concern, as hospitalization for TB is not free under the NTP. A systematic review of patient costs in sub-Saharan Africa identified hospitalization and seeking private sector, among others, as important drivers of catastrophic costs [24]. Unnecessary hospitalizations, not an uncommon practice in the private sector, should not be ignored.…”