toman's tuberculosis case detection, treatment and monitoring

MONITORING
Table 55
Estimated household costs of tuberculosis
Cost to patient Bangladesh India South Africa Uganda
(11) (12) (13) (14)
Direct costs (US$) 130 41 99 68
Lost work 57% NA NA 91%
Time loss 14 months 3 months 4 months 10 months
Lost income (US$) 115 89 272 161
Indirect cost as percentage of 15 14 NA NA
annual household income
Total cost as percentage of 31 20 NA NA
annual household income
account for more than 80% of all cases of tuberculosis. Household costs of tuberculosis
are substantial (Table 55).
Although the “direct” costs of diagnosis and treatment are significant for poor
families, the greatest economic loss occurs as a result of “indirect” costs, such as loss
of employment, travel to health facilities, sale of assets to pay for treatment-related
costs, funeral expenses, and particularly lost productivity from illness and premature
death. A study from Uganda found that 95% of subsistence farmers with tuberculosis
reported a loss in production, and 80% of wage-earners had stopped work (14). A
review of studies investigating the economic impact of tuberculosis showed that, on
average, 3–4 months of work time are lost if an adult has tuberculosis, resulting in the
loss of 20–30% of annual household income, and an average of 15 years of income is
lost if the patient dies from the disease (15).
The relation between tuberculosis and poverty is complex, as the disease impoverishes
those who suffer from it, and the epidemic is exacerbated by socioeconomic
decline. Poverty results in crowded housing with increased risk of transmission and in
poor nutrition with increased risk of breakdown from infection to tuberculosis disease.
The break-up of the Soviet Union in the early 1990s and the subsequent economic
decline and collapse of health and social support structures have led to a rapid rise in
tuberculosis, with rates increasing by 7% per year in the Russian Federation, Ukraine
and other countries of the former Soviet Union (5). In Cuba over a 3-year period, economic
and nutritional hardship resulted in a striking increase (24% per annum) in the
tuberculosis notification rate (16). A strengthened programme allowed a renewed
trend in transmission reduction, resulting in a renewed reduction in incidence.
Negative social consequences, such as stigma, are a particular problem for women
in some societies, restricting options for marriage and employment and even leading
to divorce. A study in India indicated that 15% of women with tuberculosis (equivalent
to 100 000 women per year nationally) faced rejection by their families (12).
235