Introduction
Tuberculosis (TB) remains one of the world’s deadliest infectious diseases, despite being preventable and curable. While significant progress has been made in the global fight against TB, out-of-pocket expenses continue to pose a substantial barrier to successful treatment and eradication efforts. It cannot be overemphasized, out-of-pocket expenditure in the fight against tuberculosis (TB) is a significant concern, as it can create financial barriers for patients seeking diagnosis and treatment. This article explores the impact of these expenses on TB patients and the broader implications for public health.
The Financial Burden of TB on Patients
For many TB patients, especially those in low- and middle-income countries, the cost of diagnosis and treatment can be prohibitive. Direct medical costs, such as fees for consultations, diagnostics, and medications, are just the tip of the iceberg. Patients also incur direct non-medical costs, including transportation to healthcare facilities and nutritional support during treatment. Indirect costs, such as lost wages due to illness, further exacerbate the economic burden. These out-of-pocket expenses can deter patients from seeking timely care, leading to delayed diagnosis and treatment.
Catastrophic Health Expenditure
The World Health Organization (WHO) defines catastrophic health expenditure as out-of-pocket costs that exceed 20% of a household’s annual income. Alarmingly, a significant proportion of TB-affected households face such catastrophic costs, which can push families further into poverty and hinder their ability to complete the full course of treatment.
In Tanzania for example, 44.9% of TB-affected households faced catastrophic, with the proportion rising to 80.0% among households of patients with multi-drug resistant TB (MDR-TB).
For Namibia, the percentage of TB patients and their households facing catastrophic total costs is 91% (95% CI: 83–96%). The figure for Zimbabwe stands at 82% (95% CI: 75–88%). The percentage is 68% (95% CI: 60–75%) in Nigeria, 64% (95% CI: 55–72%) in Ghana, 56% (95% CI: 47–65%) in Zambia, 54% (95% CI: 45–63%) in the Democratic Republic of Congo, 48% (95% CI: 39–57%) in South Africa, 46% (95% CI: 37–55%) in Burkina Faso, 44% (95% CI: 35–53%) in Uganda, 42% (95% CI: 33–51%) in Mali, 40% (95% CI: 31–49%) in Kenya, and 38% (95% CI: 29–47%) in Lesotho according to the 2023 WHO Global Tuberculosis Report.
The high percentages in many countries highlight the significant financial burden that TB can impose on patients and their families, emphasizing the need for comprehensive social protection measures and financial risk protection in the TB response.
An estimation of the cost of out-of-pocket expenses in African countries
Recent studies have revealed economic burdens on affected households estimated as follows:
- Concerning Direct Medical Costs, on average, patients incur around $211 per episode of TB.
- Direct Non-Medical Costs which include transportation and nutritional supplements are estimated to be $512.
- Indirect Costs that are related to the loss of income due to illness and treatment average $530 resulting in a total per-patient cost of approximately $1253.
Impact on Treatment Adherence
High out-of-pocket expenses are a major contributor to treatment non-adherence. When patients cannot afford the costs associated with TB care, they may be forced to abandon treatment prematurely. This can lead to treatment failure, relapse, and the development of drug-resistant TB strains, which are more difficult and costly to treat. As a matter of fact, the cost of treating drug-sensitive TB infection, estimated to be around $1,000 to $5,000 per patient, depending on the country and healthcare setting is significantly lower than that of treating drug-resistant strains.
These resistant strains are of two types:
- Multidrug-Resistant TB (MDR-TB): TB that is resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs, with treatment costs estimated between $5,000 to $20,000 or more per patient, depending on the duration of treatment and the drugs used.
- Extensively Drug-Resistant TB (XDR-TB): a form of MDR-TB with additional resistance to fluoroquinolones and at least one second-line injectable drug. The cost of treating this form of TB can exceed $20,000 and may go up to $100,000 or more per patient. Source: WHO, CDC,USAID
Furthermore, non-adherence to TB treatment poses a public health risk by perpetuating the cycle of transmission. For instance, When patients do not adhere to their TB treatment regimen, they remain infectious for a longer period. This increases the likelihood of transmitting the disease to others, especially in close-contact settings and also, incomplete or inconsistent treatment can lead to the development of the above mentioned drug-resistant TB strains which can spread to others, compounding the public health challenge, just to name a few.
Barriers to Accessing Care
Out-of-pocket expenses can create significant barriers to accessing TB care, particularly for vulnerable populations. Those living in rural or remote areas may face higher transportation costs, while marginalized groups may experience discrimination or stigma that discourages them from seeking care. For example, Community-based assessments in South Africa revealed that almost all people with TB experienced some form of anticipated, internal, and/or enacted stigma, which affected their engagement throughout the care cascade. Also, according to a study published in the Health and Human Rights Journal, in 15 out of 20 countries surveyed, people affected by TB reported employment discrimination, yet the majority of these countries do not have laws explicitly prohibiting such discrimination.
Additionally, the lack of social protection mechanisms in many countries means that patients must bear the full financial burden of their illness.
The Role of Social Protection
Social protection is a set of policies and programmes designed to reduce and prevent poverty, vulnerability and social exclusion throughout the life cycle (3). To mitigate the impact of out-of-pocket expenses, it is essential to strengthen social protection systems. Providing financial support, such as cash transfers or travel vouchers, can alleviate the economic burden on TB patients and improve treatment adherence. Moreover, integrating TB services into universal health coverage schemes can ensure that patients receive the care they need without facing financial hardship.
Encouragingly, some countries have taken significant steps to integrate TB services into their social protection and health coverage schemes, which helps to reduce the financial barriers to care. These include South Africa where the government provides a disability grant to TB patients who are too ill to work, as well as free TB services through the public health system and Kenya where the National Hospital Insurance Fund (NHIF) covers TB treatment and the government has introduced travel vouchers for TB patients in some regions to reduce transportation costs.
Successful interventions in TB treatment across African countries
The following interventions highlight the importance of innovative and context-specific strategies in combating TB in Africa.
- Countries like Ethiopia and Uganda have implemented community-based TB care, which has shown to be effective in improving treatment outcomes and reducing costs for patients. Ethiopia has a strong network of Health Extension Workers (HEWs) who are trained to provide basic health services, including TB care at the community level. They conduct active case finding, directly observed therapy (DOT), and follow-up of TB patients for example, while Uganda utilizes Village Health Teams (VHTs) to conduct door-to-door screening, contact tracing, and community mobilization for TB.
- Ghana, Benin, Senegal, Cameroon, Nigeria, and Guinea shared innovative experiences in systematic TB screening and active case finding during a workshop organized by the Global Fund. Ghana implemented community-based screening initiatives, leveraging local volunteers to identify and refer symptomatic individuals for testing, Benin utilized mobile clinics to reach remote areas, providing on-the-spot sputum collection and rapid molecular testing, Senegal introduced a digital platform for contact tracing and follow-up, improving the efficiency of identifying and testing contacts of TB cases, Cameroon deployed ultra-portable digital X-ray machines with computer-aided detection software to enhance case finding in hard-to-reach populations, Nigeria adopted a bi-directional screening approach, integrating TB screening with COVID-19 testing during the pandemic to maximize resources and reach and Guinea: Focused on high-risk groups, such as miners and prisoners, conducting regular screening campaigns within these populations.
- The CETA project presented by the Union has shown positive results in TB contact tracing in eight French-speaking countries. Funded by the Agence Française de Développement, the CETA project (Contributing to the Elimination of Tuberculosis in Africa) is an initiative by The Union aimed at supporting TB elimination in Africa by 2035. It focuses on TB screening and prevention, improving healthcare delivery, and strengthening the governance of national tuberculosis programs (NTPs) in eight French-speaking countries, namely Benin, Burkina Faso, Cameroon, Guinea, Central African Republic, Niger, Senegal and Togo.
- The Democratic Republic of Congo (DRC) has improved the process of identifying pediatric TB cases and providing access to preventive treatment for children contacts of people with TB by introducing new diagnostic tools such as 10-color GeneXpert and TrueNat machines, along with ultra-portable chest X-ray machines with computer-aided detection (CAD) capabilities, using Gastric aspiration and GeneXpert, stool testing for children’s diagnostics, which are less invasive and more child-friendly, implementing active TB case-finding strategies around index cases and the “TB Village” approach, using mobile units to boost diagnosis in at-risk groups and those with difficult access to services, strengthening the capacity of community health workers, to improve TB screening and referral, especially in areas with internally displaced populations (IDPs) and high-risk groups, etc.
These best practices and lessons learned should be shared to help countries adapt and implement effective measures to reduce the TB burden. It’s also crucial to establish strong partnerships with civil society and academia to further enhance the TB response in the region.
Conclusion
Out-of-pocket expenses remain a significant barrier in the fight against TB. Addressing this challenge requires a multifaceted approach that includes strengthening health systems, enhancing social protection, and ensuring equitable access to care. By reducing the financial burden on patients, we can improve treatment outcomes and move closer to the goal of eliminating TB as a global health threat. This also involves Collaboration with various sectors including health, finance and social services to address the determinants of TB, involving private healthcare providers in the TB response, engaging communities in TB prevention, case finding, and treatment support, addressing stigma associated with TB to encourage people to seek care, ensuring sufficient resources are available for TB programs and protecting patients from catastrophic costs associated with TB care among other things.
By Rose Meku
