Direct and indirect patient costs of tuberculosis care in India

Urban primary health centres in Lusaka, Zambia. 1) To estimate patient costs for tuberculosis (TB) diagnosis and treatment and 2) to identify determinants of patient costs. A cross-sectional survey of 103 adult TB patients who had been on treatment for 1-3 months was conducted using a standardised questionnaire. Direct and indirect costs were estimated, converted into US$ and categorised into two time periods: 'pre-diagnosis/care-seeking' and 'post-diagnosis/treatment'. Determinants of patient costs were analysed using multiple linear regression. The median total patient costs for diagnosis and 2 months of treatment was $24.78 (interquartile range 13.56-40.30) per patient--equivalent to 47.8% of patients' median monthly income. Sex, patient delays in seeking care and method of treatment supervision were significant predictors of total patient costs. The total direct costs as a proportion of income were higher for women than men (P < 0.001). Treatment costs incurred by patients on the clinic-based directly observed treatment strategy were more than three times greater than those incurred by patients on the self-administered treatment strategy (P < 0.001). Clinic-based treatment supervision posed a significant economic burden on patients. The creation or strengthening of community-based treatment supervision programmes would have the greatest potential impact on reducing patients' TB-related costs.

Bangalore City, India. To assess the socio-economic profile, health-seeking behaviour and costs related to tuberculosis (TB) diagnosis and treatment among patients treated under the Revised National TB Control Programme (RNTCP). All 1106 new TB patients registered for treatment under the RNTCP in the second quarter of 2005 participated. Interviews at the beginning and at the end of treatment were conducted. A convenience sample of 32 patients treated outside the RNTCP also participated. Among the TB patients, respectively 50% and 39% were from low and middle standard of living (SL) households, and 77% were from households with a per capita income of less than US$1 per day. The first health contact was with a private practitioner in the case of >70% of patients. Mean patient delay was low, at 21 days, but the mean health system delay was 52 days. The average cost incurred by patients before treatment in the RNTCP was US$145, and during treatment it was US$21. Costs as a proportion of annual household income per capita were 53% for people from low SL households and 41% for those from other households. Costs during treatment faced by patients treated outside the RNTCP averaged US$127. Patients treated under the RNTCP through a public-private mix approach were predominantly poor. Many of them experienced considerable health expenditures before starting treatment. Additional efforts are required to reduce the delays and the number of health care providers consulted, and to ensure that patients are shifted to subsidised treatment within the RNTCP.

Kota Kinabalu and surrounding communities in Sabah, Malaysia. To establish factors affecting compliance of patients with anti-tuberculosis chemotherapy, their knowledge of the disease, and views on improving the DOTS strategy. Interviews with compliant patients attending clinics for DOTS treatment and with non-compliant patients in their homes, in August and September 2000. A total of 63 compliant and 23 non-compliant patients were interviewed. For non-compliant patients, reaching the treatment centre entailed greater cost (P < 0.005) and travel time (P < 0.005) compared to compliant patients. Cost of transport was the reason most frequently given for non-attendance. Non-compliant patients were more likely to have completed secondary education (P < 0.05), and to be working (P < 0.01). More non-compliant patients had family members who had had the disease (P < 0.01). There was no difference between the groups for overall tuberculosis knowledge scores; however, non-compliant patients were more likely to think that treatment could be stopped once they were symptom free (P < 0.01). Most patients (73%) felt that the DOTS system could be improved by provision of more information about tuberculosis. Compliance with DOTS in the Kota Kinabalu area is affected by travel expenses, time spent travelling to treatment centres, and having family members who have had the disease. Patients would like more information on tuberculosis.