Inequalities in financial burden of tuberculosis among affected families across 19 low- and middle-income countries

Tuberculosis (TB) remains a major global public health problem, with majority of the cases occurring in low- and middle-income countries (LMICs). Despite its growing burden, cross-country evidence on inequalities in financial burden among affected families is limited. This study aims to assess catastrophic costs and related inequalities across 19 LMICs. The study employed a cross-country analysis of 19 national TB Patient Cost Surveys data extracted from the WHO Health Equity Assessment Toolkit (HEAT) online software. The main outcome was the percentage of families affected by TB facing catastrophic costs due to TB. Inequalities were assessed by drug resistance status, comparing drug-susceptible TB (DS-TB) and drug-resistant TB (DR-TB), using four summary measures: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF). No inferential statistics were done beyond the descriptive phase. The average percentage of TB-affected families experiencing catastrophic costs due to TB ranged from 19.2% in Lesotho to 80% in Zimbabwe. In 10 of the 19 countries, over half of TB-affected families faced catastrophic costs. When disaggregated, all countries reported higher catastrophic costs among DR-TB-affected families, except Burkina Faso. The absolute difference (D) between DR-TB and DS-TB ranged from -4% in Burkina Faso to 74.8% in Lesotho. The highest disparities were in Lesotho (D = 74.8%), Kenya (D = 60%), and Papua New Guinea (D = 51%). Ratio showed DR-TB families were up to 5.3 times more likely to experience catastrophic costs in Lesotho, with high ratios also in Kenya (3.3) and Thailand (2.6). All PAR and PAF values were negative, indicating that reducing the financial burden on DR-TB families to the level of DS-TB families could significantly lower the overall rate of catastrophic costs. The greatest potential gains were observed in Mongolia (PAR = 6%), DRC (PAR = 5%), and Brazil (PAR = 3.7%). The study showed substantial inequalities in the financial burden of TB on families across 19 LMICs, with DR-TB-affected families facing higher risks of catastrophic health cost than DS-TB families. There is an urgent need for targeted financial protection interventions, integrated within broader UHC strategies, to ensure that no TB-affected family is left behind.