Costs faced by households affected by tuberculosis in the Republic of Korea: a mixed-methods study

Abstract Background Tuberculosis (TB) continues to impose substantial financial hardship on affected households in low- and middle-income countries. Until recently, no published evidence was available from high-income countries. This study presents the first national TB household cost survey conducted in the Republic of Korea, a high-income country, to assess the magnitude and drivers of catastrophic costs and explore underlying socioeconomic mechanisms. Methods A mixed-methods study was conducted in 2024–2025. Adult patients with drug-susceptible TB (DS-TB) and drug-resistant TB (DR-TB) were recruited from selected hospitals nationwide. Structured questionnaires quantified direct medical, non-medical, and indirect costs. Catastrophic costs were defined as total TB-related expenditure exceeding 20% of pre-TB annual household income. Quality assurance included interviewer training, standardised data collection protocols, and supervisory oversight during data collection. For the qualitative component, semi-structured in-depth interviews were conducted with purposively selected participants and analysed using a framework approach. Results A total of 157 patients were included (140 DS-TB and 17 DR-TB), alongside five qualitative interviewees. Mean total costs per TB episode were USD 4,515 (95% CI, 3,473–5,557) for DS-TB and USD 7,915 (95% CI, 4,948–10,882) for DR-TB. Nutritional supplements were the largest single cost driver (38.2% of the total cost for DS-TB and 53.8% for DR-TB), followed by post-diagnosis income loss. Catastrophic costs affected 41.4% of DS-TB and 52.9% of DR-TB households. Qualitative findings revealed widespread employment disruption, sustained income loss, coping through dissaving, and psychosocial distress. Conclusions Despite comprehensive health insurance and free TB medical care, TB-affected households in Korea face substantial non-medical and indirect costs. Eliminating catastrophic costs will require social protection measures addressing income loss, caregiving demands, and non-medical expenditures alongside universal health coverage.