Implementing tuberculosis patient cost surveys in resource-constrained settings: lessons from Tanzania.

Tuberculosis (TB) disproportionally affects persons and families who are economically and socially disadvantaged. Therefore, a patient cost survey was conducted in Tanzania to evaluate the costs incurred by patients and their households before and after the diagnosis of TB. It was the first survey in Tanzania to ascertain baseline information and experience for subsequent surveys. This paper aims to share the experience encountered during the survey to ensure a standardized approach and elimination of potential barriers for the implementation of future surveys. A total of 777 TB patients from 30 clusters selected based on probability proportional to the size were interviewed during the study period. As the sample size was calculated based on notification data from the previous year, some health facilities experienced an inadequate number of TB patients during the study to meet the allocated cluster size for the survey. Most facilities had poor recording and recordkeeping in TB registers where deaths were not registered, and some patients had not been assigned district identification numbers. Fixed days for TB drug refills in health facilities affected the routine implementation of the survey as the interviews were conducted when patients visited the facility to pick up the drugs. Tablets used to collect data failed to capture the geographic location in some areas. The households of TB patients lost to follow-up and those who had died during TB treatment were not included in the survey. When planning and preparing for patient costs surveys, it is important to consider unforeseen factors which may affect planned activities and findings. During the survey in Tanzania, the identified challenges included survey logistics, communications, patient enrollment, and data management issues. To improve the quality of the findings of future surveys, it may be reasonable to revise survey procedures to include households of TB patients who were lost to follow-up and those who died during TB treatment; the households of such patients may have incurred higher direct and indirect costs than households whose patient was cured as a result of receiving TB treatment.

Economic burden of tuberculosis in Tanzania: a national survey of costs faced by tuberculosis-affected households.

BACKGROUND: Although tuberculosis (TB) care is free in Tanzania, TB-associated costs may compromise access to services and treatment adherence resulting in poor outcomes and increased risk of transmission in the community. TB can impact economically patients and their households. We assessed the economic burden of TB on patients and their households in Tanzania and identified cost drivers to inform policies and programs for potential interventions to mitigate costs. METHODS: We conducted a nationally representative cross-sectional survey using a standard methodology recommended by World Health Organization. TB patients of all ages and with all types of TB from 30 clusters across Tanzania were interviewed during July - September 2019. We used the human capital approach to assess the indirect costs and a threshold of 20% of the household annual expenditure to determine the proportion of TB-affected households experiencing catastrophic cost. We descriptively analyzed the cost data and fitted multivariable logistic regression models to identify potential predictors of catastrophic costs. RESULTS: Of the 777 TB-affected households, 44.9% faced catastrophic costs due to TB. This proportion was higher (80.0%) among households of patients with multi-drug resistant TB (MDR-TB). Overall, cost was driven by income loss while accessing TB services (33.7%), nutritional supplements (32.6%), and medical costs (15.1%). Most income loss was associated with hospitalization and time for picking up TB drugs. Most TB patients (85.9%) reported worsening financial situations due to TB, and over fifty percent (53.0%) borrowed money or sold assets to finance TB treatment. In multivariable analysis, the factors associated with catastrophic costs included hospitalization (adjusted odds ratio [aOR] = 34.9; 95% confidence interval (CI):12.5-146.17), living in semi-urban (aOR = 1.6; 95% CI:1.0-2.5) or rural areas (aOR = 2.6; 95% CI:1.8-3.7), having MDR-TB (aOR = 3.4; 95% CI:1.2-10.9), and facility-based directly-observed treatment (DOT) (aOR = 7.2; 95% CI:2.4-26.6). CONCLUSION: We found that the cost of TB care is catastrophic for almost half of the TB-affected households in Tanzania; our findings support the results from other surveys recently conducted in sub-Saharan Africa. Collaborative efforts across health, employment and social welfare sectors are imperative to minimize household costs due to TB disease and improve access to care, patient adherence and outcomes.

Evaluation of community-based interventions to improve TB case detection in a rural district of Tanzania.

In Tanzania, people with tuberculosis (TB) commonly self-medicate or visit traditional healers before seeking formal medical care. Between 2009 and 2011, we piloted a community-based project in Kisarawe District to improve TB case notification. The project trained 15 traditional healers and 15 pharmacists to identify and refer individuals with TB symptoms to diagnostic facilities. In addition, the project trained 2 community members to collect and fix sputum from symptomatic individuals onto slides, which they then delivered by bicycle to the nearest diagnostic facility. To determine effectiveness, we analyzed routine case detection data and referrals from traditional healers and pharmacists and conducted a cross-sectional survey of recently diagnosed smear-positive TB patients (N = 150) to understand their treatment-seeking behavior. From 2009 to 2011, smear-positive TB case notification increased by 68% in Kisarawe District, from 28/100,000 to 47/100,000, even while TB case notification nationally stayed the same (at approximately 14/100,000). The traditional healers and pharmacists referred 434 people with presumptive TB to diagnostic facilities, 419 of whom (97%) went to the facilities; of those who went to facilities for testing, 104 people (25%) were diagnosed with TB. The percentage of new TB case notifications that were referred through the network ranged from 38% to 70% per reporting quarter. Sputum fixers collected and delivered specimens from 178 individuals, 17 of whom (10%) were diagnosed with TB. Almost 60% of surveyed smear-positive TB patients first visited a pharmacist or traditional healer before seeking care at a diagnostic facility. These results prompted scale up of community interventions to 9 more districts in 2011 and to another 26 districts in 2013. Establishing referral networks that bring TB information and services closer to community members can contribute to improved TB case notification.