Boccia, D

Bond, V

LSHTM Research Online

LSHTM Research OnlineBoccia, D; Bond, V; (2019) The catastrophic cost of tuberculosis: advancing research and solutions.The international journal of tuberculosis and lung disease, 23 (11). pp. 1129-1130. ISSN 1027-3719DOI: https://doi.org/10.5588/ĳtld.19.0521Downloaded from: http://researchonline.lshtm.ac.uk/id/eprint/4655286/DOI: https://doi.org/10.5588/ĳtld.19.0521Usage Guidelines:Please refer to usage guidelines at https://researchonline.lshtm.ac.uk/policies.html or alternativelycontact researchonline@lshtm.ac.uk.Available under license: Copyright the publishershttps://researchonline.lshtm.ac.ukINT J TUBERC LUNG DIS 23(11):1129–1130Q 2019 The Unionhttp://dx.doi.org/10.5588/ijtld.19.0521EDITORIALThe catastrophic cost of tuberculosis: advancing research andsolutionsTHERE IS AVICIOUS CYCLE BETWEEN tubercu-losis (TB) and poverty—TB is driven by poverty andis associated with a catastrophic financial burden onaffected low-income households.1 Two recent papersfrom the same study contribute important evidence inthis area.2,3 In Limpopo Province in South Africa,28% of 323 adult TB patients experienced cata-strophic costs.2 Applying a different measurementmethod revealed high rates of deprivation (33%)among patients and higher TB episode costs inpatients from deprived households.3Erlinger et al.’s study confirms the burden imposedby TB on already vulnerable individuals and house-holds.3 It also demonstrates different approaches formeasuring catastrophic costs and stimulates debateon persisting uncertainties about optimal measure-ment strategies. For example, the authors highlightself-reported income as a less reliable measure.3 Thestudy also provides valuable insights into the designof the forthcoming South African national TB costssurvey. However, while methodology is important, itis time to move the research debate from methodo-logical issues to pragmatic solutions.Catastrophic cost is a term peculiar to TB.Complementing it with the concept of impoverish-ment, as Erlinger et al. have done,3 has the potentialto advance research in this field in our opinion. Ourunderstanding of how to measure impoverishment ismore extensive than the notion of health-relatedexpenditures. Countries could follow Erlinger et al.’slead in relying on robust methods such as the SouthAfrican Multidimensional Poverty Index (SAMPI),4to estimate the extent of impoverishment experiencedby TB-affected households and identify opportunitiesto pilot these methods within surveys on TB-relatedimpoverishment. As recommended by Erlinger et al.,3linkage to broader survey opportunities would enablea longitudinal perspective for ascertaining whetherimpoverishment is transient or chronic and determin-ing how TB shapes the life trajectory of affectedhouseholds, including children.5Most importantly, discussions on impoverishmentcould facilitate action. In this context, Stracker et al.acknowledge the role of social protection in address-ing TB-related catastrophic costs.2,3 The SouthAfrican disability grant is designed as a form of socialprotection for people being treated for TB, and in onequalitative study, the grant provided a buffer againstabsolute poverty during TB treatment.6 However, aspointed out by Stracker et al., only 5% of peoplebeing treated for TB in South Africa are reported tohave access to the local Disability Grant despiteeligibility.2 Poor access to locally available socialprotection schemes is both a missed opportunity anda largely unexplored area of research. Despite ourconsolidated understanding of how financially disas-trous it is to experience TB, we still know far lessabout how social protection schemes could be madeaccessible to TB patients, or how these could bedesigned or adapted to best meet the needs ofhouseholds living with or at risk of TB.7The above research agenda is urgent if theconsequences of TB are to be mitigated and, ideally,prevented. The creation of strong and sustainablepartnerships with stakeholders outside the TB sectorwill be key to making this research agenda affordableand impactful.D. BOCCIA1V. BOND1,21Epidemiology and Population HealthLondon School of Hygiene & Tropical MedicineLondon, UK2School of MedicineZambart ProjectLusaka, Zambiae-mail: gbond@zambart.org.zm; virginia.bond@lshtm.ac.ukConflicts of interest: none declared.References1 Tanimura T, Jaramillo E, Weil D, Raviglione M, Lo¨nnroth K.Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review. Eur Respir J 2014; 43(6):1763–1775.2 Stracker N, Hanrahan C, Mmolawa L, et al. Risk factors forcatastrophic costs associated with tuberculosis in rural SouthAfrica. Int J Tuberc Lung Dis 2019; 23(6): 756–763.3 Erlinger S, Stracker N, Hanrahan C, et al. Tuberculosis patientswith higher levels of poverty face equal or greater costs of illness.Int J Tuberc Lung Dis 2019; 23: 1205–1212.4 Statistics South Africa. The South African MPI: creating amultidimensional poverty index using census data. Pretoria,South Africa: STATSA, 2014.5 Hunleth J. Children as caregivers: the global fight againsttuberculosis and HIV in Zambia. New Brunswick, NJ, USA:Rutgers University Press, 2017.Article submitted 8 August 2019. Final version accepted 8 August 2019.6 Bond V, Chileshe M, Sullivan C, Magazi B. The convergingimpact of tuberculosis, HIV/AIDS, and food insecurity in Zambiaand South Africa. Renewal Working Paper. London, UK: Gov.UK, 2009.7 Boccia D, Pedrazzoli D, Wingfield T, et al. Towards cash transferinterventions for tuberculosis prevention, care and control: keyoperational challenges and research priorities. BMC Infect Dis2016; 16: 307.1130 The International Journal of Tuberculosis and Lung Disease

The catastrophic cost of tuberculosis: advancing research and solutions.

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The catastrophic cost of tuberculosis: advancing research and solutions.

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