The catastrophic cost of TB care: Understanding costs incurred by individuals undergoing TB care in low-, middle-, and high-income settings – A systematic review

Eliminating the burden of catastrophic costs experienced by individuals undergoing tuberculosis (TB) treatment is one of the World Health Organization (WHO) End TB Strategy targets. To help inform decisions on TB patient burden and cost-effective TB care, we conducted a systematic review to summarize current evidence around the burden of catastrophic costs incurred by individuals undergoing TB treatment and identified the main drivers of costs to aid in developing mitigation strategies. A literature search was performed in August 2024 using Embase, Web of Science, Scopus and Medline targeting studies using WHO, or WHO adapted patient costing questionnaires to measure direct (medical and non-medical) and indirect costs associated with TB care. Key cost data and patient baseline characteristics were extracted. The study protocol was registered in PROSPERO (Registration number: CRD42021293600). The systematic review included 76 studies; with 70% published over the last 5 years. Total mean costs per person for TB care ranged from $7.13 - $11,329 USD; pre-diagnostic costs ranged from $30.37 - $1,442 USD; and post-diagnostic costs ranged from $33.64 - $5,194 USD. Costs were consistently higher amongst persons with drug resistant TB (DR-TB) and those identified through passive case finding (PCF). Hospitalization and loss of income were the largest drivers of cost. Despite many countries offering free TB treatment, patients still incurred significant catastrophic costs. Our review suggests that active case finding, improving access to DR-TB testing, and adopting social protection interventions may help mitigate the burden of out-of-pocket expenditures incurred by people suffering with TB.Evidence before this study:Economic evidence examining patient costs incurred during TB treatment has previously been limited; however, following the release of the WHO “End TB Strategy” goals, there has been a rapid explosion of literature in this space. A handful of systematic reviews on the burden on catastrophic costs for TB patients have been conducted previously but they have restricted their analysis to particular geographical settings, patient populations or phases of TB care. We found no systematic review which examined the burden of these costs for patients in all stages of TB care across differing geographical settings and amongst different patient populations.Added value of this study:Our study demonstrated that despite countries offering free or subsidized TB care to their citizens, patients and their families still incurred significant catastrophic costs with many individuals resorting to coping strategies to manage the cost of care. Patients incurred a significant burden of costs throughout all stages of TB care with post-diagnostic medical components, including hospitalization and non-TB medications, having the largest impact. In addition, costs were consistently higher amongst patients with DR-TB and those who were identified using passive case finding (PCF) methods suggesting that delayed diagnosis can influence both patient outcomes as well as the burden of costs incurred during care.Implications of all the available evidence:The evidence derived from this study highlights the need for increased use of active case finding to promote early detection and diagnosis of TB, improved access to drug resistance testing, and timely access to treatment. Our study found that post diagnostic medical costs continue to have a large influence on patient costs. This finding highlights the importance of financial mitigation strategies for clients after they are diagnosed and engaged in care.