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Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 28-32

A longitudinal study to assess the cost incurred by patients undergoing treatment for tuberculosis in an urban slum community

1 District Consultant UNICEF, Nandurbar, Mumbai, Maharashtra, India
2 Department of Community Medicine, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
3 Surveillance Medical Officer, WHO, Sonbhadra, Uttar Pradesh, India
4 Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kanchipuram, Tamil Nadu, India

Date of Web Publication25-Jan-2016

Correspondence Address:
Tarun S Khandednath
District Consultant UNICEF, Nandurbar, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2394-7438.174833

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Objectives: The objective of the study was to estimate direct medical/nonmedical and indirect costs incurred by patients diagnosed with tuberculosis (TB) residing in an urban slum of Mumbai. Subjects and Methods: A longitudinal study of 16 months duration (June 2013-September 2014) was undertaken in a directly observed treatment short-course (DOTS) center of an urban slum area. The method of sampling was universal sampling and thus all the patients who were registered in the period June 2013 to December 2013 were enrolled as study participants. These subjects were then followed for their completion of treatment. All the subjects were interviewed using a semistructured questionnaire to obtain the desired information. Permission from the Institutional Ethics Committee was obtained. Statistical analysis was performed using SPSS software version 19. Results: Of the 232 patients enrolled in the study, 176 (75.9%) completed the entire course of treatment. The median direct, indirect, and total costs for 176 patients were: pretreatment direct medical cost, direct nonmedical cost, and pretreatment indirect cost was Rs. 1200 ($20), Rs. 800 ($13.3), and Rs. 1250 ($20.8), respectively. However, during the course of treatment direct medical cost, direct nonmedical cost, and indirect cost were nil, Rs. 360 ($6) and Rs. 400 ($6.6), respectively. Conclusion: Despite the free availability of diagnostic and treatment component of TB in India, the majority of the tuberculosis patients still have to spend a significant amount of money.

Keywords: Direct and indirect cost, directly observed treatment, tuberculosis, urban slum

How to cite this article:
Khandednath TS, Fernandes S, Kuwatada JS, Shrivastava SR. A longitudinal study to assess the cost incurred by patients undergoing treatment for tuberculosis in an urban slum community. MAMC J Med Sci 2016;2:28-32

How to cite this URL:
Khandednath TS, Fernandes S, Kuwatada JS, Shrivastava SR. A longitudinal study to assess the cost incurred by patients undergoing treatment for tuberculosis in an urban slum community. MAMC J Med Sci [serial online] 2016 [cited 2021 Sep 23];2:28-32. Available from: https://www.mamcjms.in/text.asp?2016/2/1/28/174833

  Introduction Top

Tuberculosis (TB) has been acknowledged as one of the major public health concerns which continues to affect the lives of millions of people worldwide not only because of the associated morbidity and mortality, but also even because of its social consequences and impact on the health care delivery system.[1],[2],[3],[4] Furthermore, TB is one of the diseases which causes heavy economic losses to humanity, both in terms of loss of disability-adjusted life years and financial burden on the family members.[1],[5],[6]

The recent estimates released by the World Health Organization (WHO) suggest that in the year 2014 in excess of 9 million people were diagnosed with TB worldwide.[7] However, more than one-fourth of these cases were reported in India alone.[7] In fact, the situation is quite alarming even in terms of drug-resistant forms of TB as again India has been ranked as one of the high burden nations.[7],[8] Nearly, 40% of the Indian population is already infected with the TB bacillus; however, the recent estimate by the WHO gives a prevalence of 3 million.[9] In India, currently TB-related prevention and control activities are organized under the Revised National Tuberculosis Control Program (RNTCP).[5]

Although, diagnostic and therapeutic services are offered at no cost to the general population nevertheless, TB patients have to spend some money directly or indirectly.[5],[10] Earlier studies have shown that patients quite often “shop around” for diagnosis before they were started on treatment under RNTCP.[11],[12],[13] The health care delivery system in India consists of a complex arrangement of government, private, and nongovernmental organization centers.[5] It was observed that 48% of patients with chest symptoms have preferred private health care facilities first.[14] Socioeconomic factors such as literacy and family income significantly influence the health care-seeking behavior and patients switched from private to government providers invariably due to financial constraints.[14],[15],[16],[17]

Even though, studies with similar objectives have been performed, most of them have been performed in developed nations and no studies in Indian settings are available.[18],[19],[20],[21],[22],[23] The current study has been conducted with an objective to study the sociodemographic profile of patients suffering from TB and to assess the direct cost (medical and nonmedical), indirect cost, and total cost (direct and indirect) incurred by the TB patients under RNTCP, among individuals residing in an urban slum area of Mumbai.

  Subjects and Methods Top

This study was performed after obtaining ethical clearance and written informed consent from the participant. This study was carried out in the Malvani urban slum area of Mumbai with a population close to 0.2 million and is being served by two health posts. However, a large number of private medical practitioner's (PMP's), nursing homes, quacks, and traditional healers were practicing in the study area apart from the public health sector establishments.

The sample population was all the patients registered during the study duration (June 2011-December 2011) under directly observed treatment short-course (DOTS) treatment.

Study type

Longitudinal descriptive study.

Study duration and sampling method

The study was conducted for a period of 16 months (June 2013-September 2014) in a DOTS center of an urban slum area. The method of sampling was universal sampling and thus all the patients who were registered in the period June 2013 to December 2013 were enrolled as study participants. These subjects were then followed for their completion of treatment – 6 months in the case of category I anti-TB treatment and 8 months for category II anti-TB treatment.

Inclusion criteria

  • All patients who were diagnosed as TB and registered under RNTCP under the health post provided they were willing to participate in the study
  • Those patients who completed the entire course of treatment successfully.

Exclusion criteria

  • Those patients who were not willing to participate in the study
  • Patients who will either default their treatment or will be transferred out or die during the course of treatment will be excluded from the study [Flow Chart 1 [Additional file 1].

Study tool

All the enrolled subjects were interviewed using a semistructured questionnaire within 7 days of their registration for their treatment to obtain the desired information. The assistance of medical social worker was taken to build rapport with the patients.

Study variables

Information pertaining to the sociodemographic attributes (viz., age, sex, education, occupation, socioeconomic status, etc.,) and amount of money spent on the diagnosis and treatment of the TB. Sociodemographic status was calculated using modified Kuppuswamy socioeconomic status classification. Subsequently, monthly interviews were taken till the completion of treatment to obtain information about their monthly expenses on travel, special food, accompanying person, loss of accompanying person's wages, debt, etc.

Operational definitions

  • Direct medical costs: Consultation fees and money spent on investigations and drugs
  • Direct nonmedical cost: Money spent on travel, stay, special food, and expenditure for persons accompanying the patient
  • Indirect costs: This includes loss of wages due to illness, decreased earning ability due to the disease, or long disability that necessitated a change in the type of work
  • Total cost: It comprises of expenditure during the pretreatment and the treatment phase under direct and indirect costs categories.

Statistical analysis

Data were entered in Microsoft Excel sheet and statistical analysis was performed using SPSS (Statistical Package for Social Sciences) version 19.0. Frequency distributions were calculated for all the variables. Out of pocket, expenditure was calculated using mean and median. The unpaired t-test was used to study the association between study variables.

  Results Top

[Table 1] presents the details about the sociodemographic profile of the study participants. It was observed that almost 131 (75%) of the enrolled subjects were from the economically productive age group 15–45 years. Among employed patients, maximum number 34% were unskilled workers, followed by homemaker 21.7%, semiskilled workers 19.8%, and 17 students, and a small percentage of 7.5% is contributed by the professional and skilled worker.
Table 1: Sociodemographic profile of the study participants

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Around 123 (69.9%) participants were Muslim by religion, and majority of the patients were from either middle or low socioeconomic class.

[Table 2] depicts the different forms of expenditure by the patient before and after starting the treatment. Overall, 125 (71%) individuals had one or more visits to the PMPs before coming to the government DOTS center for the management of their illness.
Table 2: The direct and indirect costs

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As far as the pretreatment cost (medical) is concerned, in the public health sector diagnosis of patients is made with sputum microscopy, which is free of cost, while for patients who are diagnosed with chest X-ray, a minimal charge of Rs. 10/- ($0.16) is collected from the patient as registration fee (except for the patients more than 60 years of age in which case it is free). The patients who approached the government health center for the diagnosis, but then availed laboratory services from the private sector (due to time constraints, working hours, etc.), the mean pretreatment direct (medical) cost was Rs. 628.75 ($10.4) (Rs. 0 - Rs. 10000 [$166.6]). However, those patients who went to the private sector right from the beginning until diagnosis was reached had a mean pretreatment direct (medical) cost of Rs. 4003 ($66.7) (Rs. 60 [$0.94] - Rs. 36000 [$561.4]). In fact, the difference in the pretreatment medical costs between the government and private health care establishments was found to be statistically significant (t-test = 3.622, df = 174; P = 0.001). Furthermore, unemployed patients (including children, students, and geriatric patients, had incurred more pretreatment direct (medical) cost than the employed ones [Table 2].

The median pretreatment direct (nonmedical) cost was Rs. 800 ($13.3) and the majority of the patients had spent their money on travelling, followed by accommodation and food. However, the median pretreatment indirect cost was Rs. 1250 ($20.8) and it was attributed to the loss of employment in eleven participants and to sickness absenteeism from school or workplace. In fact, because of the disease in the pretreatment period on an average 9.44 days (0–90 days) was lost [Table 2].

During the course of treatment at the health post, no direct (medical) expenditure was reported. However, median expenditure on nonmedical particulars during the course of treatment of 176 patients was Rs. 360 ($6). Further, the mean indirect cost was Rs. 1696 ($28.2) among the 106 employed study participants. Finally, the mean total cost (pretreatment direct, indirect and during treatment direct, indirect) for the 106 employed study participants who even completed the full course of treatment was Rs. 8548.49 ($142.4) (Rs. 0 - Rs. 35510 [$553.4]) [Table 2].

  Discussion Top

The findings of this study revealed that majority of the study participants were from the financially productive age group. Similar sort of results has been obtained in different epidemiological studies performed in varied settings, suggesting that TB tends to have a detrimental impact on the financial status of a family.[14],[18],[19] It was also seen that 125 (71%) patients with TB had paid one or more visits to the private sector doctors before coming to the government DOTS center for the management of their illness. This is a very common phenomenon and is being very commonly observed, resulting in a delay in the diagnosis and treatment of patients.[24] This not only results in the emergence of drug-resistant forms of TB, but also even augments the overall expenditure of families toward restoring the health of the patient.[22],[23],[25],[26]

This study showed a statistically significant relationship between the pretreatment (medical) cost between those people who approached the private sector for their first point of consultation. Similar, sort of findings were observed among the TB patients who were diagnosed and treated in an Indian city.[27] This probably results because of the minimal awareness among the PMPs about the diagnostic algorithm and the recommended guidelines, because of which most of them prescribe unnecessary diagnostic tests to confirm the diagnosis. However, at the same time the idea of making money by referring patients for unnecessary investigations can not also be overlooked.

The findings of this study showed that the median pretreatment direct (nonmedical) and pretreatment indirect cost was Rs. 800 ($13.3) and Rs. 1250 ($20.8), respectively. However, the results obtained from an urban area of Chennai showed that almost 50% of the study participants had direct pretreatment expenditure in excess of Rs. 500.[28] Furthermore, the current study depicted that the median pretreatment indirect cost was Rs. 1250 ($20.8) among the enrolled TB patients. However, results obtained from other epidemiological studies revealed lesser pretreatment expenditures, which is probably because of the period of study as they were performed earlier.[18]

It was a wonderful achievement of the program that in the study area the diagnosed TB patients had to not spend even a single rupee (direct medical cost) during the course of treatment. This is one of the crucial aspects of the national TB control program, as patients have to shell out quite significant amount of money if they are not registered in the program even during the course of therapy.[17],[29],[30] This indicates the extent of the political commitment and their pledge to ensure uninterrupted supply of therapy in Indian settings.

In addition, it was observed that for the 106 employed TB patients who participated in the study had a mean indirect expenditure of Rs. 1696 ($28.2). However, the wide range of expenditure has been obtained in different settings based on the accessibility of the health centers, health of the patient, presence of an accompanying person at the time of the visit to the DOTS center, cost of living of people, etc.[18],[28],[31],[32]

The current study estimated that the mean total cost (pretreatment direct, indirect and during treatment direct, indirect) for the 106 employed study participants who even completed the full course of treatment was Rs. 8548.49 ($142.4). However, studies performed in Tajikistan ($1053), and other Indian settings ($30 to $93) have obtained a relatively less total expenditure.[18],[31] In fact, some studies have even estimated higher total expenditure during the pretreatment and treatment phase, eventually affecting the entire socioeconomic status of the family.[16],[21],[32],[33]

The strength of our study is that it was conducted in an urban slum area, which is often not given due attention, especially considering the serious health issues prevalent in the settings. Moreover, every attempt has been made to obtain a comprehensive estimate about the overall expenditure by maintaining a good rapport with the patients. However, despite all efforts, there may be some over or underestimation of the incurred cost due to recall bias. In addition, as the study population was only those taking treatment from government health center, the estimated costs in this study may be lower than the actual costs. In addition, as the total family income of each study participant was not calculated, no inference can be drawn regarding the proportion of income being spent by the patients on TB diagnosis/treatment to assess its economic impact.

  Conclusion Top

Despite the free availability of diagnostic and treatment component of TB in India, the majority of the TB patients still have to spend a significant amount of money. Thus, it is the need of the hour to spread awareness about the different facets and services available under the program so that all individuals can obtain its benefit without spending money on unnecessary things.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sulis G, Roggi A, Matteelli A, Raviglione MC. Tuberculosis: Epidemiology and control. Mediterr J Hematol Infect Dis 2014;6:e2014070.  Back to cited text no. 1
Mjid M, Cherif J, Ben Salah N, Toujani S, Ouahchi Y, Zakhama H, et al. Tuberculosis epidemiology. Rev Pneumol Clin 2015;71:67-72.  Back to cited text no. 2
Lin HH, Wang L, Zhang H, Ruan Y, Chin DP, Dye C. Tuberculosis control in China: Use of modelling to develop targets and policies. Bull World Health Organ 2015;93:790-8.  Back to cited text no. 3
Elliott C, Hall J. Tuberculosis testing: Which patients, which test? J Fam Pract 2015;64:553-65.  Back to cited text no. 4
Kishore J. National Health Programs of India. New Delhi: Century Publications; 2012.  Back to cited text no. 5
Gulland A. Tuberculosis killed 1.5 million people in 2014. BMJ 2015;351:h5798.  Back to cited text no. 6
World Health Organization. Global TB Report 2015. Geneva: WHO Report; 2015.  Back to cited text no. 7
Sotgiu G, D'Ambrosio L, Centis R, Mura I, Castiglia P, Spanevello A, et al. The multidrug-resistant tuberculosis threat: Old problems and new solutions. J Thorac Dis 2015;7:E354-60.  Back to cited text no. 8
World Health Organization. Global TB Report 2013. Geneva: WHO Report; 2013.  Back to cited text no. 9
Özdemir T, Akkus IH, Türkkani MH, Yilmaz Aydin L. Where the tuberculosis patients are diagnosed and started to treatment? Tuberk Toraks 2015;63:185-91.  Back to cited text no. 10
Mahato RK, Laohasiriwong W, Vaeteewootacharn K, Koju R, Bhattarai R. Major delays in the diagnosis and management of tuberculosis patients in Nepal. J Clin Diagn Res 2015;9:LC05-9.  Back to cited text no. 11
Shete PB, Haguma P, Miller CR, Ochom E, Ayakaka I, Davis JL, et al. Pathways and costs of care for patients with tuberculosis symptoms in rural Uganda. Int J Tuberc Lung Dis 2015;19:912-7.  Back to cited text no. 12
Long Q, Smith H, Zhang T, Tang S, Garner P. Patient medical costs for tuberculosis treatment and impact on adherence in China: A systematic review. BMC Public Health 2011;11:393.  Back to cited text no. 13
Kirenga BJ, Ssengooba W, Muwonge C, Nakiyingi L, Kyaligonza S, Kasozi S, et al. Tuberculosis risk factors among tuberculosis patients in Kampala, Uganda: Implications for tuberculosis control. BMC Public Health 2015;15:13.  Back to cited text no. 14
Madan J, Lönnroth K, Laokri S, Squire SB. What can dissaving tell us about catastrophic costs? Linear and logistic regression analysis of the relationship between patient costs and financial coping strategies adopted by tuberculosis patients in Bangladesh, Tanzania and Bangalore, India. BMC Health Serv Res 2015;15:476.  Back to cited text no. 15
Onazi O, Gidado M, Onazi M, Daniel O, Kuye J, Obasanya O, et al. Estimating the cost of TB and its social impact on TB patients and their households. Public Health Action 2015;5:127-31.  Back to cited text no. 16
Ukwaja KN, Alobu I, Lgwenyi C, Hopewell PC. The high cost of free tuberculosis services: Patient and household costs associated with tuberculosis care in Ebonyi State, Nigeria. PLoS One 2013;8:e73134.  Back to cited text no. 17
Muniyandi M, Rajeswari R, Balasubramanian S. Cost to patient with tuberculosis treated under DOTS program. Indian J Tuberc 2005;52:188-96.  Back to cited text no. 18
Muniyandi M, Ramachandran R, Balasubramanian R, Narayanan PR. Socio-economic dimensions of tuberculosis control: Review of studies over two decades from Tuberculosis Research Center. J Commun Dis 2006;38:204-15.  Back to cited text no. 19
Fitzpatrick C, Hui Z, Lixia W, Renzhong L, Yunzhou R, Mingting C, et al. Cost-effectiveness of a comprehensive programme for drug-resistant tuberculosis in China. Bull World Health Organ 2015;93:775-84.  Back to cited text no. 20
Umar NA, Fordham R, Abubakar I, Bachmann M. The indirect cost due to pulmonary tuberculosis in patients receiving treatment in Bauchi State-Nigeria. Cost Eff Resour Alloc 2012;10:6.  Back to cited text no. 21
Ukwaja KN, Modebe O, Igwenyi C, Alobu I. The economic burden of tuberculosis care for patients and households in Africa: A systematic review. Int J Tuberc Lung Dis 2012;16:733-9.  Back to cited text no. 22
Ayé R, Wyss K, Abdualimova H, Saidaliev S. Household costs of illness during different phases of tuberculosis treatment in Central Asia: A patient survey in Tajikistan. BMC Public Health 2010;10:18.  Back to cited text no. 23
Ilangovan K, Nagaraja SB, Ananthakrishnan R, Jacob AG, Tripathy JP, Tamang D. TB treatment delays in Odisha, India: Is it expected even after these many years of RNTCP implementation? PLoS One 2015;10:e0125465.  Back to cited text no. 24
Rajeswari R, Balasubramanian R, Muniyandi M, Geetharamani S, Thresa X, Venkatesan P. Socio-economic impact of tuberculosis on patients and family in India. Int J Tuberc Lung Dis 1999;3:869-77.  Back to cited text no. 25
Grede N, Claros JM, de Pee S, Bloem M. Is there a need to mitigate the social and financial consequences of tuberculosis at the individual and household level? AIDS Behav 2014;18 Suppl 5:S542-53.  Back to cited text no. 26
Ray TK, Sharma N, Singh MM, Ingle GK. Expenses incurred by patients with tuberculosis prior to attending DOT centres. Natl Med J India 2004;17:227-8.  Back to cited text no. 27
Ananthakrishnan R, Muniyandi M, Jeyaraj A, Palani G, Sathiyasekaran BW. Expenditure pattern for TB treatment among patients registered in an urban government DOTS program in Chennai city, South India. Tuberc Res Treat 2012;2012:747924.  Back to cited text no. 28
Pantoja A, Lönnroth K, Lal SS, Chauhan LS, Uplekar M, Padma MR, et al. Economic evaluation of public-private mix for tuberculosis care and control, India. Part II. Cost and cost-effectiveness. Int J Tuberc Lung Dis 2009;13:705-12.  Back to cited text no. 29
Goodchild M, Sahu S, Wares F, Dewan P, Shukla RS, Chauhan LS, et al. Acost-benefit analysis of scaling up tuberculosis control in India. Int J Tuberc Lung Dis 2011;15:358-62.  Back to cited text no. 30
Rajeswari R, Chandrasekaran V, Suhadev M, Sivasubramaniam S, Sudha G, Renu G. Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India. Int J Tuberc Lung Dis 2002;6:789-95.  Back to cited text no. 31
Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients in low- and middle-income countries: A systematic review. Eur Respir J 2014;43:1763-75.  Back to cited text no. 32
Gurung GN, Chhetri PS, Jha N. Economic impact of pulmonary tuberculosis on patients and their families of Dharan municipality, Nepal. Nepal Med Coll J 2012;14:196-8.  Back to cited text no. 33


  [Table 1], [Table 2]


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