Household costs of illness during different phases of tuberculosis treatment in Central Asia: a patient survey in Tajikistan
Reported, January 6, 2012
Illness-related costs incurred by patients constitute a severe economic burden for households especially in low-income countries. High household costs of illness lead to impoverishment; they impair affordability and equitable access to health care and consequently hamper tuberculosis (TB) control. So far, no study has investigated patient costs of TB in the former Soviet Union.
All adult new pulmonary TB cases enrolled into the DOTS program in 12 study districts during the study period were enrolled. Medical and non-medical expenditure as well as loss of income were quantified in two interviews covering separate time periods. Costs of different items were summed up to calculate total costs. For missing values, multiple imputation was applied.
A cohort of 204 patients under DOTS, 114 men and 90 women, participated in the questionnaire survey. Total illness costs of a TB episode averaged $1053 (c. $4900 purchasing power parity, PPP), of which $292, $338 and $422 were encountered before the start of treatment, during intensive phase and in continuation phase, respectively. Costs per month were highest before the start of treatment ($145) and during intensive phase ($153) and lower during continuation phase ($95). These differences were highly significant (paired t-test, p < 0.0005 for both comparisons).
Conclusions
The illness-related costs of an episode of TB exceed the per capita GDP of $1600 PPP about two-and-a-half times. Hence, these costs are catastrophic for concerned households and suggest a high risk for impoverishment. Costs are not equally spread over time, but peak in early stages of treatment, exacerbating the problem of affordability. Mitigation strategies are needed in order to control TB in Tajikistan and may include social support to the patients as well as changes in the management of TB cases. These mitigation strategies should be timed early in treatment when the cost burden is highest.
The mean total household costs of a TB episode amounted to $1053, corresponding to $4894 PPP. While a considerable part of the scientific discussion on household costs has concentrated on the period before diagnosis , this study found that costs during treatment account for three quarters of total costs-in a setting with free TB drugs. Monthly costs were most acute before treatment and during the intensive phase. The total costs presented here do not yet take into account that patients may incur costs after the end of treatment; especially further loss of income for those who have lost their jobs.
The study may seem only partly representative of Tajikistan, as two regions had to be excluded. One of the regions (Badakhshan) is remote and very sparsely populated. The other one (Sughd) had only eight districts with an established DOTS program at the time of the study (versus 34 districts with DOTS in the whole country) and was only accessible by air in winter. The study is representative of an area of Tajikistan, from where 80% of all cases under DOTS came in the year up to the study.
As other studies on household costs, this study also relied on self-reported costs-it is thus not excluded that patients forgot or overestimated some of the costs. By using two interviews for separate periods of treatment, this study limited recall time and recall bias. Further we tried to limit the potential problem of overestimation by training the interviewers for this situation.
During an episode of TB, patients and their households face costs of approximately $4900 PPP. Comparison with the per capita GDP of $1600 PPP shows that these costs are catastrophic for the households concerned and suggest a high risk for impoverishment. Costs are not equally spread over time, but are highest in early stages of treatment, exacerbating the problem of affordability. Free TB drugs do not lead to free treatment and non-TB drugs, transport, and loss of income are very important cost drivers for patients. Mitigation strategies are needed in order to control TB in Tajikistan and may include social support to the patients as well as changes in the management of TB cases. Mitigation strategies need to be timed early in treatment when the cost burden is highest. The provision of food supplements to TB patients may contribute to somewhat alleviate the economic burden. However, our results suggest that these should be delivered soon after a TB diagnosis. Reducing the use of non-TB drugs should be considered.
Credits:Raffael Ayé,Kaspar Wyss,Hanifa Abdualimova and Sadullo Saidaliev
More Details at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822824/?tool=pubmed