Active case finding among marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis diagnosis

Glob Health Action. 2018;11(1):1494897. doi: 10.1080/16549716.2018.1494897.

Abstract

Background: There is limited evidence on whether active case finding (ACF) among marginalised and vulnerable populations mitigates the financial burden during tuberculosis (TB) diagnosis.

Objectives: To determine the effect of ACF among marginalised and vulnerable populations on prevalence and inequity of catastrophic costs due to TB diagnosis among TB-affected households when compared with passive case finding (PCF).

Methods: In 18 randomly sampled ACF districts in India, during March 2016 to February 2017, we enrolled all new sputum-smear-positive TB patients detected through ACF and an equal number of randomly selected patients detected through PCF. Direct (medical and non-medical) and indirect costs due to TB diagnosis were collected through patient interviews at their residence. We defined costs due to TB diagnosis as 'catastrophic' if the total costs (direct and indirect) due to TB diagnosis exceeded 20% of annual pre-TB household income. We used concentration curves and indices to assess the extent of inequity.

Results: When compared with patients detected through PCF (n = 231), ACF patients (n = 234) incurred lower median total costs (US$ 4.6 and 20.4, p < 0.001). The prevalence of catastrophic costs in ACF and PCF was 10.3 and 11.5% respectively. Adjusted analysis showed that patients detected through ACF had a 32% lower prevalence of catastrophic costs relative to PCF [adjusted prevalence ratio (95% CI): 0.68 (0.69, 0.97)]. The concentration indices (95% CI) for total costs in both ACF [-0.15 (-0.32, 0.11)] and PCF [-0.06 (-0.20, 0.08)] were not significantly different from the line of equality and each other. The concentration indices (95% CI) for catastrophic costs in both ACF [-0.60 (-0.81, -0.39)] and PCF [-0.58 (-0.78, -0.38)] were not significantly different from each other: however, both the curves had a significant distribution among the poorest quintiles.

Conclusion: ACF among marginalised and vulnerable populations reduced total costs and prevalence of catastrophic costs due to TB diagnosis, but could not address inequity.

Keywords: health care costs; health equity; systematic screening; tuberculosis/prevention and control; vulnerable populations.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Female
  • Health Expenditures
  • Humans
  • India / epidemiology
  • Male
  • Mass Screening / economics*
  • Middle Aged
  • Prevalence
  • Socioeconomic Factors
  • Tuberculosis / diagnosis*
  • Tuberculosis / economics*
  • Tuberculosis / epidemiology
  • Vulnerable Populations*
  • Young Adult

Grants and funding

The author(s) received no specific funding for this study. We thank The Union South-East Asia Office, New Delhi, India for funding this open-access publication. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors would like to acknowledge funding support for Project Axshya from The Global Fund TB grant to India. The Project has been implemented by the Project Management Unit of The Union South East Asia Office since 2010 to date with the support of the sub-recipient partners (in alphabetical order): The Catholic Bishops’ Conference of India-Coalition for AIDS and Related Diseases (CBCI-CARD); The Catholic Health Association of India (CHAI); Emmanuel Hospital Association (EHA); MAMTA Health Institute for Mother and Child; Population Services International (PSI); Resource Group for Education and Advocacy for Community Health (REACH); and Voluntary Health Association of India (VHAI).