title: The economic burden of TB diagnosis and treatment in South Africa.
abstract: Social protection against the cost of illness is a central policy objective of Universal Health Coverage and the post-2015 Global strategy for Tuberculosis (TB). Understanding the economic burden associated with TB illness and care is key to identifying appropriate interventions towards achieving this target. The aims of this study were to identify points in patient pathways from start of TB symptoms to treatment completion where interventions could be targeted to reduce the economic impact on patients and households, and to identify those most vulnerable to these costs. Two cohorts of patients accessing TB services from ten clinics in four provinces in South Africa were surveyed between July 2012 and June 2013. One cohort of 351 people with suspected TB were interviewed at the point of receiving a TB diagnostic and followed up six months later. Another cohort of 168 patients on TB treatment, at the same ten facilities, was interviewed at two-months and five-months on treatment. Patients were asked about their health-seeking behaviour, associated costs, income loss, and coping strategies used. Patients incurred the greatest share of TB episode costs (41%) prior to starting treatment, with the largest portion of these costs being due to income loss. Poorer patients incurred higher direct costs during treatment than those who were less poor but only 5% of those interviewed were accessing cash-transfers during treatment. Indirect costs accounted for 52% of total episode cost. Despite free TB diagnosis and care in South Africa, patients incur substantial direct and indirect costs particularly prior to starting treatment. The poorest group of patients were incurring higher costs, with fewer resources to pay for it. Both the direct and indirect cost of illness should be taken into account when setting levels of financial protection and social support, to prevent TB illness from pushing the poor further into poverty.
authors: Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa. Electronic address: Nicola.Foster@uct.ac.za.
authors: Nicola
authors: N
authors: Foster
authors: Social and Mathematical Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
authors: Anna
authors: A
authors: Vassall
authors: Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa.
authors: Susan
authors: S
authors: Cleary
authors: Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa.
authors: Lucy
authors: L
authors: Cunnama
authors: Aurum Institute, Queens Road, Parktown, Johannesburg, South Africa; Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
authors: Gavin
authors: G
authors: Churchyard
authors: Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa.
authors: Edina
authors: E
authors: Sinanovic
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D017281:Cost of Illness; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D008297:Male; D009313:National Health Programs; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012737:Sex Factors; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology; D014376:Tuberculosis / Q000191:economics* / Q000453:epidemiology; D014397:Tuberculosis, Pulmonary / Q000191:economics
keywords: Catastrophic costs; Costing; Diagnosis; Economic burden; Patient costs; South Africa; Treatment; Tuberculosis