{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,3]],"date-time":"2026-04-03T17:59:48Z","timestamp":1775239188185,"version":"3.50.1"},"reference-count":28,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2026,4,3]],"date-time":"2026-04-03T00:00:00Z","timestamp":1775174400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>Tuberculosis (TB) remains a major global public health problem, with majority of the cases occurring in low- and middle-income countries (LMICs). Despite its growing burden, cross-country evidence on inequalities in financial burden among affected families is limited. This study aims to assess catastrophic costs and related inequalities across 19 LMICs. The study employed a cross-country analysis of 19 national TB Patient Cost Surveys data extracted from the WHO Health Equity Assessment Toolkit (HEAT) online software. The main outcome was the percentage of families affected by TB facing catastrophic costs due to TB. Inequalities were assessed by drug resistance status, comparing drug-susceptible TB (DS-TB) and drug-resistant TB (DR-TB), using four summary measures: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF). No inferential statistics were done beyond the descriptive phase. The average percentage of TB-affected families experiencing catastrophic costs due to TB ranged from 19.2% in Lesotho to 80% in Zimbabwe. In 10 of the 19 countries, over half of TB-affected families faced catastrophic costs. When disaggregated, all countries reported higher catastrophic costs among DR-TB-affected families, except Burkina Faso. The absolute difference (D) between DR-TB and DS-TB ranged from \u20134% in Burkina Faso to 74.8% in Lesotho. The highest disparities were in Lesotho (D\u2009=\u200974.8%), Kenya (D\u2009=\u200960%), and Papua New Guinea (D\u2009=\u200951%). Ratio showed DR-TB families were up to 5.3 times more likely to experience catastrophic costs in Lesotho, with high ratios also in Kenya (3.3) and Thailand (2.6). All PAR and PAF values were negative, indicating that reducing the financial burden on DR-TB families to the level of DS-TB families could significantly lower the overall rate of catastrophic costs. The greatest potential gains were observed in Mongolia (PAR\u2009=\u20096%), DRC (PAR\u2009=\u20095%), and Brazil (PAR\u2009=\u20093.7%). The study showed substantial inequalities in the financial burden of TB on families across 19 LMICs, with DR-TB-affected families facing higher risks of catastrophic health cost than DS-TB families. There is an urgent need for targeted financial protection interventions, integrated within broader UHC strategies, to ensure that no TB-affected family is left behind.<\/jats:p>","DOI":"10.1371\/journal.pgph.0006172","type":"journal-article","created":{"date-parts":[[2026,4,3]],"date-time":"2026-04-03T17:23:06Z","timestamp":1775236986000},"page":"e0006172","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Inequalities in financial burden of tuberculosis among affected families across 19 low- and middle-income countries"],"prefix":"10.1371","volume":"6","author":[{"given":"Gilbert","family":"Eshun","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6040-8660","authenticated-orcid":true,"given":"Umaru","family":"Sesay","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Augustus","family":"Osborne","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2026,4,3]]},"reference":[{"key":"pgph.0006172.ref001","volume-title":"Global Tuberculosis Report 2023","author":"World Health Organization","year":"2023"},{"issue":"8","key":"pgph.0006172.ref002","doi-asserted-by":"crossref","first-page":"802","DOI":"10.5588\/ijtld.19.0694","article-title":"Cost of tuberculosis treatment in low- and middle-income countries: systematic review and meta-regression","volume":"24","author":"M Siapka","year":"2020","journal-title":"Int J Tuberc Lung Dis"},{"key":"pgph.0006172.ref003","doi-asserted-by":"crossref","first-page":"980","DOI":"10.1186\/1471-2458-12-980","article-title":"Tuberculosis and poverty: the contribution of patient costs in sub-Saharan Africa--a systematic review","volume":"12","author":"DM Barter","year":"2012","journal-title":"BMC Public Health"},{"issue":"6","key":"pgph.0006172.ref004","doi-asserted-by":"crossref","first-page":"1763","DOI":"10.1183\/09031936.00193413","article-title":"Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review","volume":"43","author":"T Tanimura","year":"2014","journal-title":"Eur Respir J"},{"issue":"10","key":"pgph.0006172.ref005","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(23)00422-9","article-title":"Families affected by catastrophic costs due to tuberculosis","volume":"11","author":"M Muniyandi","year":"2023","journal-title":"Lancet Glob Health"},{"issue":"10","key":"pgph.0006172.ref006","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(23)00369-8","article-title":"Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysis","volume":"11","author":"A Portnoy","year":"2023","journal-title":"Lancet Glob Health"},{"issue":"1","key":"pgph.0006172.ref007","doi-asserted-by":"crossref","first-page":"22361","DOI":"10.1038\/s41598-023-47094-9","article-title":"Economic burden of multidrug-resistant tuberculosis on patients and households: a global systematic review and meta-analysis","volume":"13","author":"TY Akalu","year":"2023","journal-title":"Sci Rep"},{"issue":"1","key":"pgph.0006172.ref008","doi-asserted-by":"crossref","first-page":"3111","DOI":"10.1186\/s12889-024-20664-w","article-title":"Global, regional, and national burden of tuberculosis and attributable risk factors for 204 countries and territories, 1990\u20132021: a systematic analysis for the Global Burden of Diseases 2021 study","volume":"24","author":"H Yang","year":"2024","journal-title":"BMC Public Health"},{"key":"pgph.0006172.ref009","volume-title":"The End TB Strategy","author":"World Health Organization","year":"2015"},{"issue":"4","key":"pgph.0006172.ref010","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0004283","article-title":"The catastrophic cost of TB care: Understanding costs incurred by individuals undergoing TB care in low-, middle-, and high-income settings - A systematic review","volume":"5","author":"OA D\u2019Silva","year":"2025","journal-title":"PLOS Glob Public Health"},{"key":"pgph.0006172.ref011","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/978-3-030-74786-2","article-title":"Tuberculosis Management in Developing Countries","volume-title":"Handbook of Medical and Health Sciences in Developing Countries","author":"YM Al-Worafi","year":"2023"},{"issue":"7","key":"pgph.0006172.ref012","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001675","article-title":"Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru","volume":"11","author":"T Wingfield","year":"2014","journal-title":"PLoS Med"},{"key":"pgph.0006172.ref013","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1016\/j.socscimed.2015.01.046","article-title":"The economic burden of TB diagnosis and treatment in South Africa","volume":"130","author":"N Foster","year":"2015","journal-title":"Soc Sci Med"},{"issue":"1","key":"pgph.0006172.ref014","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s40249-017-0382-3","article-title":"Catastrophic total costs in tuberculosis-affected households and their determinants since Indonesia\u2019s implementation of universal health coverage","volume":"7","author":"A Fuady","year":"2018","journal-title":"Infect Dis Poverty"},{"key":"pgph.0006172.ref015","volume-title":"Guidelines for the programmatic management of drug-resistant tuberculosis","author":"World Health Organization","year":"2019"},{"issue":"1","key":"pgph.0006172.ref016","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1186\/s12889-018-5539-x","article-title":"Modelling the impact of social protection on tuberculosis: the S-PROTECT project","volume":"18","author":"D Boccia","year":"2018","journal-title":"BMC Public Health"},{"issue":"2","key":"pgph.0006172.ref017","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0056752","article-title":"Patients are paying too much for tuberculosis: a direct cost-burden evaluation in Burkina Faso","volume":"8","author":"S Laokri","year":"2013","journal-title":"PLoS One"},{"issue":"1","key":"pgph.0006172.ref018","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1186\/s12874-016-0229-9","article-title":"Health Equity Assessment Toolkit (HEAT): software for exploring and comparing health inequalities in countries","volume":"16","author":"AR Hosseinpoor","year":"2016","journal-title":"BMC Medical Research Methodology"},{"key":"pgph.0006172.ref019","author":"WHO"},{"key":"pgph.0006172.ref020","volume-title":"Tuberculosis patient cost surveys: a hand book","author":"World Health Organization","year":"2017"},{"key":"pgph.0006172.ref021","volume-title":"Handbook on health inequality monitoring: with a special focus on low-and middle-income countries","author":"World Health Organization","year":"2013"},{"issue":"6","key":"pgph.0006172.ref022","doi-asserted-by":"crossref","first-page":"3697","DOI":"10.3390\/ijerph19063697","article-title":"Summary Measures of Health Inequality: A Review of Existing Measures and Their Application","volume":"19","author":"A Schlotheuber","year":"2022","journal-title":"Int J Environ Res Public Health"},{"issue":"6","key":"pgph.0006172.ref023","doi-asserted-by":"crossref","first-page":"1763","DOI":"10.1183\/09031936.00193413","article-title":"Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review","volume":"43","author":"T Tanimura","year":"2014","journal-title":"Eur Respir J"},{"issue":"8","key":"pgph.0006172.ref024","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0073134","article-title":"The high cost of free tuberculosis services: patient and household costs associated with tuberculosis care in Ebonyi State, Nigeria","volume":"8","author":"KN Ukwaja","year":"2013","journal-title":"PLoS One"},{"issue":"8","key":"pgph.0006172.ref025","doi-asserted-by":"crossref","first-page":"870","DOI":"10.1111\/tmi.13085","article-title":"How affordable is TB care? Findings from a nationwide TB patient cost survey in Ghana","volume":"23","author":"D Pedrazzoli","year":"2018","journal-title":"Trop Med Int Health"},{"issue":"6","key":"pgph.0006172.ref026","doi-asserted-by":"crossref","first-page":"733","DOI":"10.5588\/ijtld.11.0193","article-title":"The economic burden of tuberculosis care for patients and households in Africa: a systematic review","volume":"16","author":"KN Ukwaja","year":"2012","journal-title":"Int J Tuberc Lung Dis"},{"issue":"1","key":"pgph.0006172.ref027","doi-asserted-by":"crossref","first-page":"1409","DOI":"10.1186\/s12889-020-09524-5","article-title":"Households experiencing catastrophic costs due to tuberculosis in Uganda: magnitude and cost drivers","volume":"20","author":"W Muttamba","year":"2020","journal-title":"BMC Public Health"},{"key":"pgph.0006172.ref028","author":"B Bello","year":"2020"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006172","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,3]],"date-time":"2026-04-03T17:23:11Z","timestamp":1775236991000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006172"}},"subtitle":[],"editor":[{"given":"Alice","family":"Zwerling","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2026,4,3]]},"references-count":28,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4,3]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0006172","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,3]]}}}