Estimating tuberculosis-related patient costs in KwaZulu-Natal, South Africa

Abstract Summary In a cross-sectional study, we calculated direct and indirect costs incurred by people prior to starting tuberculosis (TB) treatment in primary healthcare facilities in KwaZulu-Natal, South Africa. We related the total costs to patient income to explore the economic impact of TB care-seeking and contribute to the literature by exploring differences between those with and without TB symptoms. Background Patient costs during tuberculosis (TB) treatment in South Africa are high. There are fewer data about the costs incurred prior to starting treatment. We measured pre-TB treatment costs for people in rural KwaZulu-Natal, South Africa. Design/methods In the context of a TB case-contact study, we interviewed people starting TB treatment at primary healthcare facilities in rural South Africa. We estimated total direct and indirect costs incurred by respondents and their households in the three months prior to starting TB treatment. We estimated other coping costs, such as selling productive assets, as well as the value of any loans taken. Results Among 98 participants (52 female, median age 36 years), 86/98 (88%) reported one or more symptoms from the WHO 4-symptom TB screening tool prior to starting treatment. The median total pre-treatment cost for TB affected households was USD 10.78 (IQR: [4.13 – 20.23]). Total, pre-treatment costs for those with TB symptoms were USD 10.78 (IQR: [4.83 – 20.23]) compared to USD 8.91 (IQR: [1.27 – 22.19]) for those without TB symptoms. Conclusions Whilst TB testing and care is free in South African public health facilities, patients still face costs that are burdensome. Our results indicate people affected by TB, including patients and their families, also face an economic burden. Our study highlights the need for further consideration of social protection policies to reduce the economic effects of asymptomatic TB. Key Messages While TB testing and treatment are free in South African public health facilities, patients still face significant financial costs related to TB care-seeking. There is limited evidence on the economic costs incurred prior to starting treatment, particularly regarding the difference between people with and without TB symptoms. People without TB symptoms faced similar pre-treatment costs compared to those with TB symptoms. In rural South Africa, reducing pre-treatment costs for those without TB symptoms may justify active case-finding initiatives to identify these people earlier.