Costs faced by multi-drug resistant tuberculosis patients during diagnosis and treatment. Report from a pilot study in Ethiopia.

January 2014

Ethiopia has a high prevalence of tuberculosis (TB) and is one of the 22 highest TB burden countries in the world. It is also one of the countries where many people who develop TB every year do not get treated. One of the reasons why infected people delay or do not seek diagnosis and treatment is economic access – the cost to patients and their families. Delays in seeking care and interruptions in treatment can result in transmission of the infection to other people and interruptions in treatment can also result in multi-drug resistant TB.

A study of MDR-TB patient costs in March 2013 indicated that the average total out-of-pocket cost for an MDR-TB patient to get diagnosis and treatment was US$ 1,341 and each patient lost, on average, US$ 293 of income due to time spent seeking and receiving care (excluding income losses due purely to inability to work). Of the 169 MDR-TB patients that were interviewed, 82% were hospitalized at some stage and on average each patient spent 80 days in hospital. To get a correct diagnosis, it took patients an average of 3 visits with each visit taking an average of 22 hours.

The impact on patient employment and on overall patient and family income was catastrophic. Of the 169 MDR-TB patients, 121 (72%) reported losing their jobs and 133 (79%) reported an average income reduction of 100% for themselves and 33% for their families. The average out-of-pocket cost of US$ 1,341 represented over 2 years of the annual post-illness family income.

Patients financed the costs in various ways. Sixty five (38%) of the MDR-TB patients sold some type of property, 12 (7%) leased out property and 69 (41%) took out loans from family or friends. Of the 148 MDR- TB patients under treatment, 108 (73%) received vouchers funded through donor assistance, mostly for food, transport and house rental costs. The average total value of these vouchers was US$ 33 per MDR-TB patient, which appears to be very low compared with the patient costs.

The hospital reports indicated that an estimated 29% of the patients diagnosed with MDR-TB did not start treatment and 3% of the patients who started treatment defaulted. This study indicates that unaffordable patient costs with limited or no social support could be a contributing factor, along with geographical access issues.

In a national workshop held to discuss the findings, several key mitigation recommendations were agreed upon. These included ensuring that the policy of free care for all MDR-TB services is fully implemented, that services are brought closer to patients, and that the provision of social support to patients is improved. 

Recommendations were also made for further research. These include interviewing more DS-TB patients across the country, reviewing the norms to see if the numbers of MDR-TB visits and length of stay in hospital can be reduced, and assessing the distribution and availability of MDR-TB diagnostic services. In addition, it will be important to gather data from people MDR-TB who are not receiving care since these are, presumably, the people who have the greatest problems with access. Finally it is worth looking at the feasibility of collecting patient access and cost data routinely through short interviews in facilities and by including questions in patient satisfaction surveys. 

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