Mitigating costs for people living with TB: from measurement to action

It is well understood that TB is a consequence of poverty: we must similarly understand that TB may also be a cause of poverty. The recent paper by Sinha et al. adds important evidence on the financial burden of TB, particularly on the high indirect costs faced by people living with TB in India, who face mean indirect costs of US$667.00.¹

Lost income associated with loss of employment or time lost while seeking or staying in care accounted for the largest single share of total costs in a number of countries that conducted nationally representative patient cost surveys.² In India, the majority of these costs were incurred pre-diagnosis or during the intensive phase of treatment. Indirect costs incurred through job loss and lost wages especially can fuel cycles of poverty, and the measurement of such costs demonstrates how TB leads to impoverishment.

As the authors suggest in their article, the Indian direct benefit transfer (DBT) for people living with TB provides a strong opportunity to break the cycle of poverty through the provision of in-kind or cash support, alongside other existing social protection strategies. However, people living with TB are regularly not covered by suitable social protection systems or these programmes do not meet their specific needs.^3,4 A recent mixed-methods study demonstrated that there are still substantial delays and barriers to accessing DBT, affecting the ability of patients to defray their costs.⁵ As the majority of costs in the Indian context are pre-diagnosis, facilitating better access to social protection for those most vulnerable to TB might defray costs even before interaction with the health system.

As indirect costs due to job loss are such a large component of total costs, providing more comprehensive social protection floors is warranted. Public health action could be taken through promoting or legislating policies that can support job retention for people living with TB, such as paid sick leave or flexible working arrangements. Other possibilities for integrating social action with biomedical approaches may entail having screening or preventive treatment available in the workplace, alongside the creation of links with trade unions and other organisations that protect workers. Such policies also provide the opportunity to reduce stigma. While the TB community is slowly moving towards action on direct costs, policies that address indirect costs have so far been overlooked, as they require true multisectoral action and dialogue.⁶

Studies such as Sinha et al.’s are invaluable for quantifying costs. As the evidence base on the presence of catastrophic costs becomes increasingly strong, the international TB community must start effectively using this wealth of knowledge to inform policies and practices that can alleviate the financial burden of the disease. This study provides yet another call for the TB community to think beyond biomedical approaches for mitigating catastrophic costs and other consequences of TB. Social protection alone may not be a silver bullet, but it remains an underutilised tool in the arsenal for the fight against TB.