Household catastrophic expenditure for tuberculosis care among adults = 18 years in Pakistan: Incidence, its determinants and policy implications

<b>Background:</b> Despite free tuberculosis treatment, hidden expenditure incurred by patients and its household may push them into a catastrophic state and devastating economic impact create an adherence barrier and less financial accessibility towards treatment. The study aimed to determine the incidence of catastrophic expenditure, its determinants and policy implications among adults ≥18 years in Pakistan. <b>Methods:</b> A public facility-based cross-sectional study was conducted in Karachi where 516 TB patients were interviewed using a standardized “tool to estimate patient9s costs”. Direct costs, food expenditure and loss of income were determined and household catastrophic payment was computed using ≥40% of non-food income, as suggested by the World Health Organization. Logistic regression analysis was applied to determine the factors behind catastrophic payments. <b>Results:</b> The total median cost [IQR] for TB care was US$143.6[109.9–191.5], with direct non-medical and indirect costs contributing 17% and 40%, respectively. The incidence of catastrophic expenditure was 18%; with 54% and 10% of the poorest and richest wealth-quintiles facing catastrophic activity, respectively. Independent determinants of catastrophic payments were: age ≥40 years (aOR:1.8, 95% CI:1.1-3.4), male gender (aOR:2.0, 95% CI:1.3-4.5), poor household (aOR:3.2, 95% CI:2.0-7.5), hospitalization (aOR:3.9, 95% CI:2.1-6.5) and patient; the primary earner (aOR:3.7, 95% CI:1.8-7.1). <b>Conclusions:</b> Current policies for free TB care are not enough. Increasing financial protection through in-patient coverage, food, and travel vouchers and paid leave benefits should be added.