The catastrophic cost of TB care: Understanding costs incurred by individuals undergoing TB care in low-, middle-, and high-income settings - A systematic review.

Eliminating the burden of catastrophic costs experienced by individuals undergoing tuberculosis (TB) treatment is one of the World Health Organization (WHO) End TB Strategy targets. To help inform decisions on TB patient burden and cost-effective TB care, we conducted a systematic review to summarize current evidence around the burden of catastrophic costs incurred by individuals undergoing TB treatment and identified the main drivers of costs to aid in developing mitigation strategies. A literature search was performed in August 2024 using Embase, Web of Science, Scopus and Medline targeting studies using WHO, or WHO adapted patient costing questionnaires to measure direct (medical and non-medical) and indirect costs associated with TB care. Key cost data and patient baseline characteristics were extracted. The study protocol was registered in PROSPERO (Registration number: CRD42021293600). The systematic review included 76 studies; with 70% published over the last 5 years. Total mean costs per person for TB care ranged from $7.13 - $11,329 USD; pre-diagnostic costs ranged from $30.37 - $1,442 USD; and post-diagnostic costs ranged from $33.64 - $5,194 USD. Costs were consistently higher amongst persons with drug resistant TB (DR-TB) and those identified through passive case finding (PCF). Hospitalization and loss of income were the largest drivers of cost. Despite many countries offering free TB treatment, patients still incurred significant catastrophic costs. Our review suggests that active case finding, improving access to DR-TB testing, and adopting social protection interventions may help mitigate the burden of out-of-pocket expenditures incurred by people suffering with TB.