Burden of catastrophic costs, income inequalities and associated factors in Guatemala: First national tuberculosis costs survey, 2023

OBJECTIVES: To estimate the prevalence of catastrophic costs incurred by households of people with tuberculosis (TB) in Guatemala, and to assess the potential wealth inequalities and the associated factors with the catastrophic costs, social consequences and coping strategies. METHODS: A national representative survey, employing a clustered sampling based on health facilities, was conducted in 2023. The participants were people with TB and the data was collected by trained professionals using a standardized questionnaire. Catastrophic costs were defined as costs incurred by TB treatment that exceeds 20% of annual household income. We estimated the burden of catastrophic costs, social consequences and coping strategies. The primary analysis encompassed the output approach, while sensitivity analyses were conducted with the human capital approach and income loss adjustments. The associations were assessed using Poisson regression models with robust variance. RESULTS: The First Guatemala National Tuberculosis Costs Survey had 530 participants enrolled in 42 clusters. The estimated catastrophic costs incurred by people with TB, through the output approach, was 36% (95% CI 29% - 43%). The prevalence among the poorest wealth quintile was 66%, while among the richest it was 50%, throughout the output approach adjusted for income loss (sensitivity analysis). Catastrophic costs were twice as high for 15-44-years old, but lower for people in the South West (PR 0.72; 95% CI 0.55-0.94), those in five-plus-person households (PR 0.73; 95% CI 0.57-0.93), and those treated in primary/secondary facilities (PR 0.69; 95% CI 0.49-0.97). Social effects were related with sociodemographic characteristics and catastrophic costs (PR 1.21; 95% CI 1.09-1.34). Coping strategies were associated with sociodemographic factors, presence of social support (PR 1.11; 95% CI 1.01-1.22), and TB type (PR 1.16; 95% CI 1.01-1.33). CONCLUSION: In Guatemala, catastrophic costs were identified as a burden characterized by inequities, posing a challenge to the country in achieving zero to this indicator. However, the analyses revealed pathways that could be prioritized when formulating policies to effectively address this issue.