Pretreatment Out-of-Pocket Expenses for Presumptive Multidrug-Resistant Tuberculosis Patients, India, 2016–2017

In India, under the National Tuberculosis Elimination Programme, the government provides free treatment for multidrug-resistant tuberculosis; however, many patients seek care elsewhere, which is costly. To determine those out-of-pocket expenses, we interviewed 40 presumptive patients and found that they spent more than their median annual income before registering for the government program.

MDR TB cases are referred to PMDT centers. Persons with MDR TB are admitted to the PMDT center for a week for pretreatment evaluation at no cost to the patient (5, 6).
This study was conducted as a part of output oriented operational research which was a time bound program. Therefore, we included all cases of adult MDR (≥ 15 years) registered under PMDT between August 2016 and April 2017 (9 months) in the study. The period of data collection was same as period of recruitment of patients in the study.
Assuming that XDR patient's pre-diagnostic and treatment trajectory is more complicated as compared to the MDR patient in India. Their number of visits to other Healthcare facilities prior to reaching PMDT center is more and hence the costs of Pre-diagnosis if included with MDRTB patients, may show an overestimation of expenditure. Hence, we decided to exclude them from study.
Information on various costs incurred was collected during an interview using a pretested, semi-structured tool. Costs incurred from the time they were presumptive MDR TB till the time they registered under PMDT and underwent pretreatment evaluation were collected with the help of study tool. The study tool was used to gather information on socio-demographic characteristics, reported income, various healthcare facilities (HCFs) visited, direct and indirect costs of diagnosis and pretreatment evaluation, and any potential coping mechanisms needed to maintain livelihood during this time (e.g., loans, selling off assets, and donations). Information of various costs reported by patients were validated with the bills, if available. Socio-economic status was measured using Modified BG Prasad classification (7). Those MDR-TB patients who were admitted during the study period were interviewed face-to-face (n = 16), while patients who and EpiData analysis 2.2.2.183 software (8,9). The direct cost was further divided into direct medical and direct non-medical. The direct medical cost was calculated by simple addition of cost of consultancy, investigation, treatment. The direct non-medical was costs involved in transport, accommodation, food for both patient and attendant, if any. The indirect cost was summation of loss of wage or salary due to MDRTB. The direct and indirect costs were added to estimate total cost. Apart from these, the various coping mechanisms, adopted by the patients and their family to cover the medical and household expenses (for e.g., borrowing money, taking loan, selling assets, children's school dropouts) were included in calculating coping cost and The inflated local currency was then converted back to USD using 2016 conversion rate for uniformity (10).
The median direct out-of-pocket expenditures (for examinations, laboratory testing, non-TB medications) for our patients was $105($49-306). This was substantially higher than the adjusted cost values of previous comparable studies conducted in Indonesia ($47), Peru ($67), and Ethiopia ($87), but lower than a report from Ecuador ($549) and Cambodia ($144). (12)(13)(14)(15) The median total pretreatment out-of-pocket expenditure experienced by families in our study was $171($72-432). After adjustment, the total out-of-pocket expenditure costs in Cambodia ($394), and Peru ($210) were slightly lower, suggesting that indirect costs were an important component of overall pretreatment costs (12,13). Our results were in contrast to studies Page 4 of 9 conducted by van den Hof et al. in Ethiopia and Indonesia. They found substantially lower total median pretreatment costs after adjustment ($171 vs $95, and $55, respectively) (14). Variation in results could be due to methodological differences in data collection and analysis. van  Ecuador found more than ten times adjusted indirect costs ($51 vs $578) and overall adjusted pretreatment costs ($171 vs $1126) as compared to our results (13,15). This could be attributed to steep rise in inflation rates in Ecuador (16,17).
Health seeking behavior among patients: We also found out the pattern of health seeking behavior of our patient. Majority (n=24, 60%) of the patients approached the private health care sector for the first clinical contact, while subsequently, proportion of patients visiting public health care sector rose.

Glossary of operational definitions used in the study
Presumptive MDR case (6) Catastrophic Cost (19): The WHO End TB Strategy suggests that any cost ≥20% of their total family income is considered as catastrophic and is associated with poor outcomes Costs adjustment (11,16,17) represents product of all values in the range of series.