title: Patients direct costs to undergo TB diagnosis.
abstract: BACKGROUND
  A major impediment to the treatment of TB is a diagnostic process that requires multiple visits. Descriptions of patient costs associated with diagnosis use different protocols and are not comparable.
  
  
  METHODS
  We aimed to describe the direct costs incurred by adults attending TB diagnostic centres in four countries and factors associated with expenditure for diagnosis. Surveys of 2225 adults attending smear-microscopy centres in Nigeria, Nepal, Ethiopia and Yemen. Adults >18 years with cough >2 weeks were enrolled prospectively. Direct costs were quantified using structured questionnaires. Patients with costs >75(th) quartile were considered to have high expenditure (cases) and compared with patients with costs <75(th) quartile to identify factors associated with high expenditure.
  
  
  RESULTS
  The most significant expenses were due to clinic fees and transport. Most participants attended the centres with companions. High expenditure was associated with attending with company, residing in rural areas/other towns and illiteracy.
  
  
  CONCLUSIONS
  The costs incurred by patients are substantial and share common patterns across countries. Removing user fees, transparent charging policies and reimbursing clinic expenses would reduce the poverty-inducing effects of direct diagnostic costs. In locations with limited resources, support could be prioritised for those most at risk of high expenditure; those who are illiterate, attend the service with company and rural residents.
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
authors.forename: Rachel M Anderson
authors.initials: RM
authors.lastname: de Cuevas
authors.affiliation: Zankli Medical Center, Abuja, Nigeria.|Bingham University, Nassarawa State, Abuja, Nigeria.
authors.forename: Lovett
authors.initials: L
authors.lastname: Lawson
authors.affiliation: Medical Faculty, Sana'a University, Sana'a, Yemen.
authors.forename: Najla
authors.initials: N
authors.lastname: Al-Sonboli
authors.affiliation: National Tuberculosis Institute, Sana'a, Yemen.
authors.forename: Nasher
authors.initials: N
authors.lastname: Al-Aghbari
authors.affiliation: Bushullo Major Health Centre, Awassa, Ethiopia.
authors.forename: Isabel
authors.initials: I
authors.lastname: Arbide
authors.affiliation: Tribhuvan University Institute of Medicine, Kathmandu, Nepal.
authors.forename: Jeevan B
authors.initials: JB
authors.lastname: Sherchand
authors.affiliation: Zankli Medical Center, Abuja, Nigeria.
authors.forename: Emenyonu E
authors.initials: EE
authors.lastname: Nnamdi
authors.affiliation: Armauer Hansen Research Institute, Addis Ababa, Ethiopia.
authors.forename: Abraham
authors.initials: A
authors.lastname: Aseffa
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.|The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Yassin
authors.affiliation: Federal Capital Territory Tuberculosis and Leprosy Control Programme, Abuja, Nigeria.
authors.forename: Saddiq T
authors.initials: ST
authors.lastname: Abdurrahman
authors.affiliation: Nigeria Tuberculosis and Leprosy Control Programme, Abuja, Nigeria.
authors.forename: Joshua
authors.initials: J
authors.lastname: Obasanya
authors.affiliation: Zankli Medical Center, Abuja, Nigeria.
authors.forename: Oladimeji
authors.initials: O
authors.lastname: Olanrewaju
authors.affiliation: REACH Ethiopia, Hawassa, Ethiopia.
authors.forename: Daniel
authors.initials: D
authors.lastname: Datiko
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
authors.forename: Sally J
authors.initials: SJ
authors.lastname: Theobald
authors.affiliation: UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ramsay
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
authors.forename: S Bertel
authors.initials: SB
authors.lastname: Squire
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. Luis.Cuevas@lstmed.ac.uk.
authors.forename: Luis E
authors.identifier: http://orcid.org/0000-0002-6581-0587
authors.initials: LE
authors.lastname: Cuevas
mesh_terms: D000328:Adult; D000368:Aged; D017281:Cost of Illness; D005260:Female; D005102:Health Expenditures; D006801:Humans; D008297:Male; D008875:Middle Aged; D009390:Nepal; D009549:Nigeria; D011446:Prospective Studies; D012424:Rural Population; D014376:Tuberculosis / Q000175:diagnosis* / Q000191:economics*; D015006:Yemen; D055815:Young Adult
keywords: Access to healthcare; Costs; Ethiopia; Nepal; Nigeria; Tuberculosis; Yemen