Despite major medical advances in the world, tuberculosis continues to be a highly prevalent disease in low and middle income countries and a major cause of adult death.
Tuberculosis is associated with poverty, and adults with limited income, poor nutrition and poor access to health services are disproportionately affected. Poverty and tuberculosis constitute a vicious circle.
Poor individuals are more likely to become infected because of their poor housing conditions which facilitate transmission and less likely to fence off the infection because of the poor nutrition. Poverty increases the likelihood of having tuberculosis, while tuberculosis increases poverty.
Unfortunately, the diagnosis of tuberculosis is part of this circle, as it requires the examination of the sputum (saliva and mucus coughed up from the respiratory tract) using an old test (smear microscopy) or the use of newer and more sensitive tests, such as Xpert.
Smear microscopy however requires multiple examinations and the patients needs to return several times to the services, while Xpert is mostly available in reference or selected district hospitals
Smear microscopy however requires multiple examinations and the patients needs to return several times to the services, while Xpert is mostly available in reference or selected district hospitals because it can only function in laboratories that are well equipped.
Poor patients therefore often seek medical help late in the course of their illness, and when they visit they face the cost of multiple visits to the health centres. Not surprisingly, the cost of attending the health services often represents a high proportion of their income and the loss of earnings can lead to catastrophic costs for the family.
What did we investigate?
We describe here the direct (patient) costs incurred by adults attending TB diagnostic centres in four countries, in a study that used the same methods and tools to identify the factors that are common across the countries.
Costs for all patients were not homogeneous, as for example a male patient who lives nearby a health centre is more likely to attend the health centre early, has low transport costs and attends on his own, without the need for company. We also compared patients with high expenditure across the four countries with patients who incurred lower costs.
Perhaps not very surprisingly, the most significant expenses were related to the cost of transport.
Perhaps not very surprisingly, the most significant expenses were related to the cost of transport. Another significant expenditure was due to clinic fees. Although in some countries these fees are reimbursed if the patient is shown to have tuberculosis, only a minority (5%-20%) of patients with chronic cough are finally confirmed to have the disease.
Most patients therefore have to incur the expenditure and fees are not reimbursed. Most participants, especially females, also attended the centres with companions, which necessarily increased the cost of transport.
One of the new Sustainable Development Goals for tuberculosis aims to eliminate catastrophic costs for patients with tuberculosis. Health systems therefore need to be aware that in poor settings, individuals who have high expenditure for diagnosis are those who for their frailty, lack of confidence or societal and gender reasons need to attend with company.
This is particularly pertinent to individuals to reside in rural areas and who have poor education. Furthermore, despite treatment for tuberculosis already being free in most if not all health services in the world, a major cost to access the free treatment is the cost of diagnosis and until health services address this barrier, access to free treatment will be limited by the cost of diagnosis.