Pre-treatment direct costs for people with tuberculosis during the COVID-19 pandemic in different healthcare settings in Bandung, Indonesia

The tuberculosis (TB) program was massively disrupted due to the COVID-19 pandemic, which may have impacted on an increase in costs for people with TB (PWTB) and their households. We aimed to quantify the pre-treatment out-of-pocket costs and the factors associated with these costs from patients' perspective during the COVID-19 pandemic in Bandung, Indonesia. Adults with pulmonary TB were interviewed using a structured questionnaire for this cross-sectional study recruiting from 7 hospitals, 59 private practitioners, and 10 community health centers (CHCs) between July 2021 to February 2022. Costs in rupiah were converted into US dollars and presented as a median and interquartile range (IQR). Factors associated with costs were identified using quantile regression. A total of 252 participants were recruited. The median total pre-treatment cost was $35.45 (IQR 17.69-67.62). The highest median cost was experienced by participants from private hospitals ($54.51, IQR 29.48-98.47). The rapid antigen and PCR for SARS-CoV-2 emerged as additional medical costs among 26% of participants recruited in private hospitals. Visiting ≥ 6 providers before diagnosis ($38.40 versus $26.20, p < 0.001), presenting first at a private hospital ($50.68, p < 0.05) and private practitioners ($34.97, p < 0.05), and being diagnosed in the private health sector ($39.98 versus $20.30, p < 0.05) were significantly associated with higher pre-treatment costs. PWTB experienced substantial out-of-pocket costs in the process of diagnosis during the COVID-19 pandemic despite free TB diagnosis and treatment. Early detection and identification play an important role in reducing pre-diagnostic TB costs.