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A patient care pathway analysis was used to estimate the extent, level and distribution of direct costs associated with TB (n = 229). By breaking down direct costs of the successive stages of the TB patient pathway in rural Burkina Faso, the figure highlights the gap between the national TB control strategy and the effective patient care pathway. Most patients accumulated medical and non-medical out-of-pocket expenses at every single stage of their care pathway. Moreover, it showed three kinds of delays which were respectively patient delay in the pre-diagnosis period, provider delay related to diagnosis, and treatment delay related to treatment initiation stage.
Source publication
Paying for health care may exclude poor people. Burkina Faso adopted the DOTS strategy implementing "free care" for Tuberculosis (TB) diagnosis and treatment. This should increase universal health coverage and help to overcome social and economic barriers to health access.
Straddling 2007 and 2008, in-depth interviews were conducted over a year amo...
Citations
... One study from Pakistan has shown that the cost during the pre-diagnostic phase and the indirect cost contribute 49% and 42% of the total household out-of-pocket payment for TB care [37]. Previous reports have also showed the higher cost of the post-diagnosis DOT strategy [9,[38][39][40][41]. The cost incurred by TB patients also depends on the kind of pace where these patients came from. ...
Background
Despite the diagnosis and treatment of tuberculosis (TB) given free of charge in many high-burden countries, the costs that patients face in the cascade of care remain a major concern. Here, we aimed to investigate the financial burden of TB diagnosis and treatment for people with TB in Ethiopia.
Method
For this systematic review and meta-analysis, we searched PubMed/MEDLINE, Embase, and Cochrane Center for Clinical Trials from December 1 2022 to 31 June 2023 for articles reporting the cost of diagnosis and treatment for patients regardless of their age with all forms of TB in Ethiopia. Major study outcomes were catastrophic costs, direct (out-of-pocket) pre-diagnosis, medical cost, and post-diagnosis costs, indirect (income loss) costs, coping costs, and total costs. We have used a threshold of 20% to define catastrophic costs. We used random-effects meta-analyses to calculate summary estimates of costs. R-studio software was used for analysis. The study is registered with PROSPERO: CRD42023387687.
Result
Twelve studies, with a total of 4792 patients with TB, were included in our analysis. At the 20% threshold of total expenses, 51% of patients (2301 participants from 5 studies, 95% CI: 36-65%, I² = 97%) faced catastrophic costs due to bacteriologically confirmed drug-sensitive pulmonary TB. Private facility diagnosis, drug-resistance TB, TB-HIV co-infection, hospitalization, and occupation were found to be associated with catastrophic costs. Reduction in the total cost spent by the patients was associated with digital adherence interventions, community-based direct observed therapy, short-course MDR-TB treatment regimens, and active case-finding. Pre-diagnosis costs had a positive correlation with diagnosis delays and the number of facilities visited until diagnosis. Post-diagnosis costs had a positive correlation with rural residence and inpatient treatments.
Conclusion
Irrespective of a national policy of free TB service, more than half of TB patients are suffering catastrophic costs due to drug-sensitive pulmonary TB in Ethiopia and most of the patients spend a lot of money during the pre-diagnosis period and intensive phase, but declined drastically over time. Active case-finding, digital adherence interventions, community-based treatment, and comprehensive health insurance coverage have the potential to minimize the financial burden of TB diagnosis and treatment.
... Moreover, passive case finding result in high-income losses before diagnosis and treatment due to health system delays [21]. People incur substantial direct and indirect costs to access care for TB in settings where programs provide free TB services [33]. ...
Introduction
The standard passive case-finding strategy implemented by most developing countries is inadequate to detect new cases of Tuberculosis. A household contact investigation is an alternative approach. However, there is limited cost-effectiveness data to support planning and implementation in low and middle-income countries. The study aimed to evaluate the cost-effectiveness of adding household contact investigation (HCI) to the passive case-finding (PCF) strategy in the Tuberculosis control program in Southwestern Uganda.
Methods
We conducted an economic evaluation using a retrospective study approach and bottom-up costing (ingredients) techniques. It was a synthesis-based evaluation of existing data extracted from the District Health Information System (DHIS 2), TB registers, and a primary cost survey. The study compared two methods of Tuberculosis (TB) case finding (PCF and HCI) strategies. Regarding PCF, patients either self-reported their signs and symptoms or were prompted by healthcare workers. At the same time, HCI was done by home visiting and screening contacts of TB patients. Patients and household contacts presumed to have Tuberculosis were requested to produce samples for analysis. We applied a static decision-analytic modeling framework to examine both strategies’ costs and effectiveness. The study relied on cost and probability estimates from National Tuberculosis (TB) program data, activity costs, and published literature. It was performed from the societal and provider perspectives over 1.5 years across 12 facilities in Ntungamo, Sheema, and Rwampara Districts. The primary effectiveness measure was the number of TB cases detected (yield) and the number needed to screen (NNS). The TB yield was calculated from the number of patients screened during the period under study. The incremental cost-effectiveness ratio (ICER) was expressed as cost in 2021 US$ per additional TB case detected. We did not apply a discount rate because of the short analytic time horizon.
Results
The unit costs of detecting a Tuberculosis case were US$ (United States dollar) 204.22 for PCF and US$ 315.07 for HCI. Patient and caregiver costs are five times more in PCF than in HCI [US$26.37 Vs. US$ 5.42]. The ICER was US$ 3,596.94 per additional TB case detected. The TB screening yields were 0.52% (1496/289140) for passive case finding and 5.8% (197/3414) for household contact investigation. Household contact investigation yield among children 0–14 Vs. 15+ years [6.2% Vs.5.4%] P = 0 . 04 . The Yield among People living with HIV (PLHIV) Vs. HIV-negative [15.8% Vs.5.3%] P = 0.03 in HHCI. The PCF yield in men Vs. Women [1.12% Vs.0.28%] P <0.01. The NNS in PCF was 193 [95% CI: 186–294] and 17 [95% CI: 14–22] in HCI.
Conclusion
Our baseline assumptions and the specific implementations of adding HCI to existing PCF programs in the context of rural African settings prove to be not cost-effective, rather than HCI as a strategy. HCI effectively identifies children and PLHIV with TB and should be prioritized. Meanwhile, the Passive case-finding strategy effectively finds men with TB and costs lower than household contact investigation.
... These differences can be partly explained by the rising cost of living occasioned by inflation, increase in the prices of medicines and laboratory investigations, and the reduction of the purchasing power of the Nigerian naira to the United States dollar. Direct costs of illness in TB in Cambodia and Burkina Faso also reported similar values with this study, USD137 and USD120 respectively (Pichenda et al., 2012;Laokri et al., 2013). In addition, average direct medical and direct nonmedical costs for DM patients for this study revealed NGN87,155.08 ...
Background: Diabetes mellitus (DM) increases the risk of developing tuberculosis (TB) three-fold. The cost of accessing care for TB-DM co-morbidity poses a significant burden on patients, as they bear both direct and indirect costs of treatment, mostly of out-of-pocket.Objective: To estimate the direct medical cost of illness in patients with TB-DM co-morbidity in two chest clinics in Lagos State.Materials and Methods: An observational study, carried out in two chest clinics in Lagos State to evaluate direct medical costs associated with TBDM co-morbidity during TB treatment. A semi structured questionnaire, pharmacy price list of drugs and an online transportation service lara.ng was employed to document and quantify prescribed medications, laboratory investigations, number of clinic attendance and attendant transportation costs.Results: Among the participants, 53.8% were females. The mean age was 50.7±9.7 years. The total direct medical and non-medical costs for TBDM management was NGN8,604,819 (USD24,585.20) for the duration of TB treatment. Average cost per patient (CPP) was NGN179,384.85 (USD512.53). This was equivalent to 49.8% of the current national minimum wage. Male patients incurred more mean direct medical cost than female patients (NGN26, 647.90 vs NGN24, 020.40), while female patients incurred more mean direct non-medical costs than the males (NGN22, 314.30 versus NGN13, 041.70). Patients aged 60 years and above incurred the highest mean direct costs compared to other age groups.Conclusion: Direct medical costs are substantial in TBDM co-morbidity and increase with age.
... Evidence in the literature suggests that people have to travel long distances to access TB services, incurring considerable direct and indirect costs. 7 Previous studies have also shown that poor access to TB services leads to delayed health seeking, thereby delaying diagnosis and treatment. 8,9 Although a courier system is used to transport sputum samples from the District TB Centre to the CDST laboratory, patients have difficulties reaching the District TB Centre to provide the samples; sputum transportation should therefore be decentralised to prevent loss to follow-up. ...
Setting: All multidrug-resistant tuberculosis (MDR-TB)
patients who had completed 6 months of treatment under
the Revised National Tuberculosis Control Programme
(RNTCP) in Uttar Pradesh, the largest state in northern
India.
Objective: To determine the proportion of MDR-TB patients
with regular follow-up examinations, and underlying
provider and patient perspectives of follow-up
services.
Methods: A retrospective cohort study was undertaken
involving record reviews of 64 eligible MDR-TB patients
registered during April–June 2013 in 11 districts of the
state. Patients and programme personnel from the selected
districts were interviewed using a semi-structured
questionnaire.
Results: A total of 34 (53.1%) patients underwent follow-
up sputum culture at month 3, 43 (67.2%) at month
4, 36 (56.3%) at month 5 and 37 (57.8%) at month 6.
Themes associated with irregular follow-up that emerged
from the interviews were multiple visits, long travel distances,
shortages of equipment at the facility and lack of
knowledge among patients regarding the follow-up
schedule.
Conclusion: The majority of the MDR-TB patients had irregular
follow-up visits. Provider-related factors outweigh
patient-related factors on the poor follow-up examinations.
The programme should focus on the decentralisation of follow-
up services and ensure logistics and patient-centred
counselling to improve the regularisation of follow up.
... Failure in health-care delivery has been shown to increase the risk of catastrophe, exacerbate socio-economic iniquities, and reduce the probability of comprehensive treatment. 45 These findings therefore reiterate the need for policymakers to develop mechanisms to improve quality of care for diabetic patients in public health facilities since this has serious cost implications on patients. Additionally, since more than three quarters (76.7%) of the patients reported attending their routine scheduled clinics monthly, introducing mechanisms to minimize facility visits, for example, by enhancing and supporting self-care by patients is likely to reduce transport costs. ...
Objective:
To estimate the direct and indirect costs of diabetes mellitus care at five public health facilities in Kenya.
Methods:
We conducted a cross-sectional study in two counties where diabetes patients aged 18 years and above were interviewed. Data on care-seeking costs were obtained from 163 patients seeking diabetes care at five public facilities using the cost-of-illness approach. Medicines and user charges were classified as direct health care costs while expenses on transport, food, and accommodation were classified as direct non-health care costs. Productivity losses due to diabetes were classified as indirect costs. We computed annual direct and indirect costs borne by these patients.
Results:
More than half (57.7%) of sampled patients had hypertension comorbidity. Overall, the mean annual direct patient cost was KES 53 907 (95% CI, 43 625.4-64 188.6) (US$ 528.5 [95% CI, 427.7-629.3]). Medicines accounted for 52.4%, transport 22.6%, user charges 17.5%, and food 7.5% of total direct costs. Overall mean annual indirect cost was KES 23 174 (95% CI, 20 910-25 438.8) (US$ 227.2 [95% CI, 205-249.4]). Patients reporting hypertension comorbidity incurred higher costs compared with diabetes-only patients. The incidence of catastrophic costs was 63.1% (95% CI, 55.7-70.7) and increased to 75.4% (95% CI, 68.3-82.1) when transport costs were included.
Conclusion:
There are substantial direct and indirect costs borne by diabetic patients in seeking care from public facilities in Kenya. High incidence of catastrophic costs suggests diabetes services are unaffordable to majority of diabetic patients and illustrate the urgent need to improve financial risk protection to ensure access to care.
... respectively. These suggests that many households would be unable to cope with TB treatment without certain coping strategies like selling or leasing their assets as well as borrowing of loans (Laokri et al., 2013;Ukwaja et al., 2013;Collins et al., 2013). ...
... 18 to 61% of patients received financial assistance from outside their household to cope with the cost of TB care (Ukwaja et al., 2012). Laokri et al., 2013 also reported that the poor would be unable to finance TB treatment without certain coping strategies. ...
... The total health expenditure post-intervention increased remarkably. One reason may be that improvement in the reimbursement rate for TB patients promoted an increase in the demand for TB services and treatment compliance [31]. Some studies have shown that poverty is a main factor restricting the utilization of TB health services, and failure to adhere to the complete treatment cycle of TB care still exists in many areas of China [19,32]. ...
... Case-based payments were the preferred option. Compared with a fee-for-services approach, this was seen as one way to reduce the provision of unnecessary services [9,31]. However, inadequate implementation weakened any impact of cost control, contributing to the high level of OOP. ...
Background:
Tuberculosis (TB) is still a major public health problem in China. To scale up TB control, an innovative programme entitled the 'China-Gates Foundation Collaboration on TB Control in China was initiated in 2009. During the second phase of the project, a policy of increased reimbursement rates under the New Cooperative Medical Scheme (NCMS) was implemented. In this paper, we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data.
Methods:
In two cross-sectional surveys, quantitative data were collected before (January 2010 to December 2012) and after (April 2014 to June 2015) the intervention in the existing NCMS routine data system. Information on all 313 TB inpatients, among which 117 inpatients in the project was collected. Qualitative data collection included 11 focus group discussions. Three main indicators, non-reimbursable expenses rate (NER), effective reimbursement rate (ERR), and out-of-pocket payment (OOP) as a percentage of per capita household income, were used to measure the impact of intervention by comprising post-intervention data with baseline data. The quantitative data were analysed by descriptive analysis and non-parametric tests (Mann-Whitney U test) using SPSS 22.0, and qualitative data were subjected to thematic framework analysis using Nvivo10.
Results:
The nominal reimbursement rates for inpatient care were no less than 80% for services within the package. Total inpatient expenses greatly increased, with an average growth rate of 11.3%. For all TB inpatients, the ERR for inpatient care increased from 52 to 66%. Compared with inpatients outside the project, for inpatients covered by the new policy, the ERR was higher (78%), and OOP showed a sharper decline. In addition, their financial burden decreased significantly.
Conclusions:
Although the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy, inpatient OOP expenditure was still a major financial problem for patients. Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement. Comprehensive control models are needed to effectively decrease the financial burden on all TB patients.
... Weak institutional capacity of health facilities including stock-outs of drugs/supplies, inadequate spacing and infrastructure, lack of training, high workload, low staff motivation, and poor coordination of health centre services hindered efficient and effective TB service delivery [16]. High cost of TB care, despite free care policy, reduced equity in use of TB services [17][18][19]. Few studies highlight good governance practices. ...
... Whereas transaction cost and stigma among patients limited equity and inclusiveness of TB care, the willingness to pay for TB services for self and others was high in this review. The findings about transaction cost is consistent with evidence of high cost of TB care despite free care policy in Burkina Faso, South Africa and China [17,18,76] and point to the need to include TB in universal health coverage schemes that offer financial protection [24]. The UHC schemes, which could also harness altruistic contributions, would address the need of the poor and vulnerable population and enhance sustainability of the TB programme [55,76]. ...
Background:
The role of governance in strengthening tuberculosis (TB) control has received little research attention. This review provides evidence of how institutional designs and organisational practices influence implementation of the national TB control programme (NTP) in Nigeria.
Main text:
We conducted a scoping review using a five-stage framework to review published and grey literature in English, on implementation of Nigeria's NTP and identified themes related to governance using a health system governance framework. We included articles, of all study designs and methods, which described or analysed the processes of implementing TB control based on relevance to the research question. The review shows a dearth of studies which examined the role of governance in TB control in Nigeria. Although costed plans and policy coordination framework exist, public spending on TB control is low. While stakeholders' involvement in TB control is increasing, institutional capacity is limited, especially in the private sector. TB-specific legislation is absent. Deployment and transfer of staff to the NTP are not transparent. Health workers are not transparent in communicating service entitlements to users. Despite existence of supportive policies, integration of TB control into the community and general health services have been weak. Willingness to pay for TB services is high, however, transaction cost and stigma among patients limit equity. Effectiveness and efficiency of the NTP was hindered by inadequate human resources, dilapidated service delivery infrastructure and weak drug supply system. Despite adhering to standardized recording and reporting format, regular monitoring and evaluation, revision of reporting formats, and electronic data management system, TB surveillance system was found to be weak. Delay in TB diagnosis and initiation of care, poor staff attitude to patients, lack of privacy, poor management of drug reactions and absence of infection control measures breach ethical standards for TB care.
Conclusions:
This scoping review of governance of TB control in Nigeria highlights two main issues. Governance for strengthening TB control programmes in low-resource, high TB burden settings like Nigeria, is imperative. Secondly, there is a need for empirical studies involving detailed analysis of different dimensions of governance of TB control.
... Early diagnosis is expected to lead to early treatment initiation and hence better outcomes. Improved diagnostic tools may facilitate early diagnosis and reduce the direct costs of the diagnostic burden on patients and family [5,6]. Currently, Ziehl-Neelsen (ZN) stain-based microscopy, GeneXpert and Light Emitting Diode-Fluorescence Microscopy (LED-FM) are widely used diagnostic tools for drug-sensitive pulmonary tuberculosis by National TB programmes in high burden countries. ...
Background
Early and accurate diagnosis of tuberculosis is a priority for TB programs globally to initiate treatment early and improve treatment outcomes. Currently, Ziehl–Neelsen (ZN) stain-based microscopy, GeneXpert and Light Emitting Diode-Fluorescence Microscopy (LED-FM) are used for diagnosing pulmonary drug sensitive tuberculosis. Published evidence synthesising the cost-effectiveness of these diagnostic tools is scarce.
Methodology
PubMed, EMBASE and Cost-effectiveness analysis registry were searched for studies that reported on the cost-effectiveness of GeneXpert and LED-FM, compared to ZN microscopy for diagnosing pulmonary TB. Risk of bias was assessed independently by four authors using the Consensus Health Economic Criteria (CHEC) extended checklist. The data variables included the study settings, population, type of intervention, type of comparator, year of study, duration of study, type of study design, costs for the test and the comparator and effectiveness indicators. Incremental cost-effectiveness ratio (ICER) was used for assessing the relative cost-effectiveness in this review.
Results
Of the 496 studies identified by the search, thirteen studies were included after removing duplicates and studies that did not fulfil inclusion criteria. Four studies compared LED-FM with ZN and nine studies compared GeneXpert with ZN. Three studies used patient cohorts and eight were modelling studies with hypothetical cohorts used to evaluate cost-effectiveness. All these studies were conducted from a health system perspective, with four studies utilising cost utility analysis. There were considerable variations in costing parameters and effectiveness indicators that precluded meta-analysis. The key findings from the included studies suggest that LED-FM and GeneXpert may be cost effective for pulmonary TB diagnosis from a health system perspective.
Conclusion
Our review identifies a consistent trend of the cost effectiveness of LED-FM and GeneXpert for pulmonary TB diagnosis in different countries with diverse context of socio-economic condition, HIV burden and geographical distribution. However, all the studies used different parameters to estimate the impact of these tools and this underscores the need for improving the methodological issues related to the conduct and reporting of cost-effectiveness studies.
... Total reported amounts were used and the sum of itemized expenditures were imputed to the total reported for missing values. Based on a review of previous studies [20][21][22][23], a framework of potential drivers of OOPs was used to consider demand-and supply-side explanatory variables (Fig. 1). Characteristics related to the demand for care consisted of individual demographic characteristics, household composition and status, socio-economic factors, illness, or care-seeking behavior while those related to the supply of care services referred to the availability and perceived quality of care, and affordability of care. ...
Abstract Background The goal of universal health coverage is challenging for chronically under-resourced health systems. Although household out-of-pocket payments are the most important source of health financing in low-income countries, relatively little is known about the drivers of primary health care expenditure and the predictability of the burden associated with high fee-for-service payments. This study describes out-of-pocket health expenditure and investigates demand- and supply-side drivers of excessive costs in the Democratic Republic of Congo (DRC), a central African country in the midst of a process of reforming its health financing system towards universal health coverage. Methods A population-based household survey was conducted in four provinces of the DRC in 2014. Data included type, level and utilization of health care services, accessibility to care, patient satisfaction and disaggregated health care expenditure. Multivariate logistic regressions of excessive expenditure for outpatient care using alternative thresholds were performed to explore the incidence and predictors of atypically high expenditure incurred by individuals. Results Over 17% (17.5%) of individuals living in sample households reported an illness or injury without being hospitalized. Of 3341 individuals reporting an event in the four-week period prior to the survey, 65.6% sought outpatient care with an average of one visit (SD = 0.0). The overall mean expenditure per visit was US$ 6.7 (SD = 10.4) with 29.4% incurring excessive expenditure. The main predictors of a financial risk burden included utilizing public services offering the complementary benefit package, dissatisfaction with care received, being a member of a large household, expenditure composition, severity of illness, residence and wealth (p
