title: Can Malawi's poor afford free tuberculosis services? Patient and household costs associated with a tuberculosis diagnosis in Lilongwe.
abstract: OBJECTIVE
  To assess the relative costs of accessing a TB diagnosis for the poor and for women in urban Lilongwe, Malawi, a setting where public health services are accessible within 6 kilometers and provided free of charge.
  
  
  METHODS
  Patient and household direct and opportunity costs were assessed from a survey of 179 TB patients, systematically sampled from all public and mission health facilities in Lilongwe. Poverty status was determined from the 1998 Malawi Integrated Household Survey (MIHS).
  
  
  RESULTS
  On average, patients spent US$ 13 (MK 996 or 18 days' income) and lost 22 days from work while accessing a TB diagnosis. For non-poor patients, the total costs amounted to 129% of total monthly income, or 184% after food expenditures. For the poor, this cost rose to 248% of monthly income or 574% after food. When a woman or when the poor are sick, the opportunity costs faced by their households are greater.
  
  
  CONCLUSIONS
  Patient and household costs of TB diagnosis are prohibitively high even where services are provided free of charge. In scaling up TB services to reach the Millennium Development Goals, there is an urgent need to identify strategies for diagnosing TB that are cost-effective for the poor and their households.
authors.affiliation: Equi-TB Knowledge Programme, Malawi and Liverpool School of Tropical Medicine, UK. jkemp@africa-online.net
authors.forename: Julia R
authors.initials: JR
authors.lastname: Kemp
authors.forename: Gillian
authors.initials: G
authors.lastname: Mann
authors.forename: Bertha Nhlema
authors.initials: BN
authors.lastname: Simwaka
authors.forename: Felix Ml
authors.initials: FM
authors.lastname: Salaniponi
authors.forename: Stephen Bertel
authors.initials: SB
authors.lastname: Squire
mesh_terms: D000995:Antitubercular Agents / Q000627:therapeutic use; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D005260:Female; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics* / Q000458:organization & administration; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D011203:Poverty; D014186:Transportation; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000188:drug therapy / Q000191:economics*
chemical_list: D000995:Antitubercular Agents