Preplanned Studies: Financial Burden of Tuberculosis Patients — China, 2020

Tuberculosis (TB) is often regarded as “a disease of poverty”. In China, a basic package of free services (including chest radiography, sputum smear test, and first-line drugs) is provided to TB cases, while other costs are covered by public-funded medical insurance schemes. However, there is limited information available on whether the current policy is sufficient to avoid the heavy economic burden of TB care. To address this, a cross-sectional study involving primary data collection was conducted in 41 counties in China in 2020 to obtain a nationally representative assessment of the financial burden of TB care. The results showed that the direct costs, indirect costs, and total costs due to TB care were 1041.3 USD, 12.7 USD, and 1185.5 USD per patient, respectively. Direct costs accounted for 88% and 37% of costs incurred before patients arrived at TB-designated hospitals. Governments need to increase TB investment and improve medical insurance levels. Doctors from TB-designated hospitals should conduct TB diagnosis and treatment in accordance with norms and guidelines to reduce total costs. Health staff of general hospitals should also improve awareness of TB and refer presumptive TB patients to TB-designated medical facilities in a timely manner, thus reducing delays in TB care and costs before they reach TB-designated hospitals.

The End TB Strategy aims to ensure that by 2020, no households affected by TB will experience catastrophic costs due to the disease (1). This is in line with the World Health Organization’s (WHO) policy to move health systems closer to universal health coverage (UHC) (2). Despite the availability of free TB care services and public-funded medical insurance systems, TB patients in some regions still face a heavy financial burden. However, there is no nationally representative data on this issue in China.

This TB patient cost survey was part of a comprehensive evaluation of the National Tuberculosis Prevention and Control Plan (2016–2020). The survey was conducted between October and December 2020, in accordance with the WHO recommended methodology (3). The study population was defined as drug-susceptible pulmonary TB patients who had received at least two weeks of therapy under the National Tuberculosis Programme (NTP). Assuming a catastrophic cost due to TB of 50%, a relative precision of 0.2, and an alpha error of 0.05, the average cluster size (defined at the county level) for each designated TB medical institution was calculated as 0.83, and the effective response rate was set at 80%. Thus, the sample size was determined to be a total of 2,250 patients in 41 institutions. The main stratification factors considered in multistage stratified sampling were urban and rural areas. According to the proportion of registered tuberculosis patients in urban and rural areas in 2019 (51.9% and 48.1%), the number of designated medical institutions in urban and rural areas was determined to be 21 and 20, respectively. Face-to-face interviews were conducted by trained investigators using a structured questionnaire. Patients presented health insurance cards and treatment fee documents, if available. Data were double-entered and validated using EpiData (version 3.1 EpiData Association, Odense, Denmark). The analysis was conducted using STATA (version 12.1, copyright 1985–2011 StataCorp LP USA). A currency exchange rate of 645 CNY to 100 USD (December 2020) was used. The operational definitions were as follows: 1) Direct medical costs: Out-of-pocket (OOP) medical expenditures associated with TB diagnosis, treatment, and treatment-seeking; 2) Direct non-medical costs: OOP costs for transportation, accommodation, and food of the patients and family members; 3) Direct costs: Direct medical and direct non-medical costs combined; 4) Indirect costs: Productivity and economic costs of a patient and their household incurred as a result of TB care visits and hospitalization during the TB episode; 5) Total costs: Direct and indirect costs combined.

A total of 3,286 TB patients were surveyed, of whom 2,201 (67.0%) were male. The median (interquartile range, IQR) monthly income per capita was 148 USD (61.7–246.7). The incomes of 704 (21.4%) households were below the poverty line. The New Rural Cooperative Medical Scheme (NRCMS) covered 2,394 (72.8%) of the patients (Table 1). The total TB care costs were 1185.5 USD (596.0–2230.8). The total TB care costs were relatively high among people over 65 years old (χ²=50.3, P<0.0001), divorced and widowed (χ²=52.6, P<0.0001), those in the western region (χ²=14.4, P=0.0008), those in rural areas (χ²=9.2, P=0.0025), those with education below primary school (χ²=16.6, P=0.0023), those without insurance (χ²=44.9, P<0.0001), and those in low-income household (χ²=40.6, P<0.0001) (Table 1). The median (IQR) direct, indirect, and total costs due to TB care were 1041.3 USD (534.5−1965.0), 12.7 USD (0.2–194.3), and 1185.5 USD (596.0–2230.8) per patient, respectively (Table 2). The direct costs accounted for 88.0% of the total costs, while the direct medical costs accounted for 69% of total costs. Of the total costs, 37% were incurred before patients arrived at TB-designated hospitals (Figure 1).

Figure 1. 

Contribution of each component of costs due to TB care as a proportion of total costs among patients enrolled in TB patient cost survey, China, 2020 (N=3,286).