Background: Studies on costs incurred by patients for tuberculosis (TB) care are limited as these costs are reported
as averages, and the economic impact of the costs is estimated based on average patient/household incomes.
Average expenditures do not represent the poor because they spend less on treatment compared to other
economic groups. Thus, the extent to which TB expenditures risk sending households into, or further into, poverty
and its determinants, is unknown. We assessed the incidence and determinants of household catastrophic
payments for TB care in rural Nigeria.
Methods: Data used were obtained from a survey of 452 pulmonary TB patients sampled from three rural health
facilities in Ebonyi State, Nigeria. Using household direct costs and income data, we analyzed the incidence of
household catastrophic payments using, as thresholds, the traditional >10% of household income and the =40% of
non-food income, as recommended by the World Health Organization. We used logistic regression analysis to
identify the determinants of catastrophic payments.
Results: Average direct household costs for TB were US$157 or 14% of average annual incomes. The incidence
catastrophic payment was 44%; with 69% and 15% of the poorest and richest household income-quartiles
experiencing catastrophic activity, respectively. Independent determinants of catastrophic payments were: age
>40 years (adjusted odds ratio [aOR] 3.9; 95% confidence interval [CI], 2.0, 7.8), male gender (aOR 3.0; CI 1.8, 5.2),
urban residence (aOR 3.8; CI 1.9, 7.7), formal education (aOR 4.7; CI 2.5, 8.9), care at a private facility (aOR 2.9; 1.5,
5.9), poor household (aOR 6.7; CI 3.7, 12), household where the patient is the primary earner (aOR 3.8; CI 2.2, 6.6]),
and HIV co-infection (aOR 3.1; CI 1.7, 5.6).
Conclusions: Current cost-lowering strategies are not enough to prevent households from incurring catastrophic
out-of-pocket payments for TB care. Financial and social protection interventions are needed for identified at-risk
groups, and community-level interventions may reduce inefficiencies in the care-seeking pathway. These
observations should inform post-2015 TB strategies and influence policy-making on health services that are meant
to be free of charge.