Catastrophic costs of tuberculosis care: a mixed methods study from Puducherry, India

Background: The average expenditure incurred by patients in low- and middle-income countries towards diagnosis and treatment of TB ranges from $55 to $8198. This out-of-pocket expenditure leads to impoverishment of households. One of the three main targets of the End TB Strategy (2016-2035) is that no TB-affected household suffers catastrophic costs due to TB. Study setting was free care under national tuberculosis program (NTP), Puducherry district, India.Objectives: The objectives of the study were among the newly diagnosed and previously treated tuberculosis (TB) patients, to (a) estimate patient costs during diagnosis and intensive phase of treatment, (b) determine the proportion of households experiencing catastrophic costs, and (c) explore coping strategies.Methods: An explanatory mixed methods design comprising both quantitative cost description and qualitative descriptive component was used. Catastrophic cost was defined as total TB care costs exceeding 20% of annual household income.Results: Of 102 TB patients included, two-thirds (69%) were male, 6% were HIV positive, and 45% reported at least one episode of hospitalization for TB care. The median (IQR) total cost of TB care was US$195 (52.1, 492.9) with a direct cost of US$65.3 (22.3, 156.5) and indirect cost of US$50.2 (0.9, 295.1). Overall, 32.4% of households experienced catastrophic costs due to TB care, significantly higher in patients with HIV coinfection (p=0.009) and hospitalization (p=0.009). Pledging jewels and borrowing money were major coping strategies. Cash assistance was the expected remedy from the patient perspective.Conclusion: Despite free TB care under NTP, more than a third incurred catastrophic costs towards TB care.