Risk factors for catastrophic costs associated with tuberculosis in rural South Africa

SETTING: Fifty-five public clinics in northern South Africa. OBJECTIVE : To estimate patient costs and identify the factors associated with catastrophic costs among individuals treated for tuberculosis (TB). DESIGN: We performed cross-sectional interviews of consecutive patients at public clinics from October 2017 to January 2018. 'Catastrophic costs' were defined as costs totalling ≥20% of annual household income. For participants with no reported income, we considered scenarios where costs were considered non-catastrophic if 1) costs totalled ,US$7.70 (ZAR100) or 2) a multidimensional poverty index was above a certain threshold. RESULT S : Among 327 participants, the estimated mean TB episode costs were US$365 (95%CI 233-498): Outof- pocket costs comprised 58% of costs, wages lost due to health care-seeking represented 26%, and income reduction accounted for 16% of costs. Ninety (28%) participants experienced catastrophic costs, which were associated with clinic travel times of 60-90 min (adjusted prevalence ratio [aPR] 1.7, 95%CI 0.9-3.1), unemployment (aPR 2.0, 95%CI 1.0-4.0) and having fewer household members (aPR 0.6, 95%CI 0.3-1.0). CONCLUS IONS : In rural South Africa, catastrophic costs from TB are common and associated with distance to clinics, unemployment, and household size. These findings can help tailor social protection programs and enhance service delivery to patients at greatest risk of experiencing financial hardship.