title: Assessing the economic burden of illness for tuberculosis patients in Benin: determinants and consequences of catastrophic health expenditures and inequities.
abstract: OBJECTIVE
  To inform policy-making, we measured the risk, causes and consequences of catastrophic expenditures for tuberculosis and investigated potential inequities.
  
  
  METHODS
  Between August 2008 and February 2009, a cross-sectional study was conducted among all (245) smear-positive pulmonary tuberculosis patients of six health districts from southern Benin. A standardised survey questionnaire covered the period of time elapsing from onset of tuberculosis symptoms to completion of treatment. Total direct cost exceeding the conventional 10% threshold of annual income was defined as catastrophic and used as principal outcome in a multivariable logistic regression. A sensitivity analysis was performed while varying the thresholds.
  
  
  RESULTS
  A pure gradient of direct costs of tuberculosis in relation to income was observed. Incidence (78.1%) and intensity (14.8%) of catastrophic expenditure were high; varying thresholds was insensitive to the intensity. Incurring catastrophic expenditure was independently associated with lower- and middle-income quintiles (adjusted odd ratio (aOR) = 36.2, 95% CI [12.3-106.3] and aOR = 6.4 [2.8-14.6]), adverse pre-diagnosis stage (aOR = 5.4 [2.2-13.3]) and less education (aOR = 4.1[1.9-8.7]). Households incurred important days lost due to TB, indebtedness (37.1%), dissaving (51.0%) and other coping strategies (52.7%).
  
  
  CONCLUSIONS
  Catastrophic direct costs and substantial indirect and coping costs may persist under the 'free' tuberculosis diagnosis and treatment strategy, as well as inequities in financial hardship.
authors.affiliation: Health Policy and Systems, Université Libre de Bruxelles, Brussels, Belgium.
authors.forename: Samia
authors.initials: S
authors.lastname: Laokri
authors.forename: Michèle
authors.initials: M
authors.lastname: Dramaix-Wilmet
authors.forename: Ferdinand
authors.initials: F
authors.lastname: Kassa
authors.forename: Séverin
authors.initials: S
authors.lastname: Anagonou
authors.forename: Bruno
authors.initials: B
authors.lastname: Dujardin
mesh_terms: D000328:Adult; D000368:Aged; D001541:Benin; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D003625:Data Collection; D005191:Family Characteristics; D005260:Female; D005382:Financing, Personal; D005102:Health Expenditures; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012959:Socioeconomic Factors; D014397:Tuberculosis, Pulmonary / Q000191:economics*; D055815:Young Adult
keywords: Bottom-up decision-making; Catastrophic health expenditure; Cost of illness; Coste de la enfermedad; Economía de la salud; Financial and social protection; Health economics; Informed policy-making; coût de la maladie; décision de politique éclairée; dépenses de santé catastrophiques; gasto sanitario catastrófico; prise de décision évolutive; protección financiera y social; protection financière et sociale; toma de decisiones fundadas; toma de decisión ascendente; économie de la santé