https://orcid.org/0009-0002-9444-4325
Figures
Abstract
Eliminating the burden of catastrophic costs experienced by individuals undergoing tuberculosis (TB) treatment is one of the World Health Organization (WHO) End TB Strategy targets. To help inform decisions on TB patient burden and cost-effective TB care, we conducted a systematic review to summarize current evidence around the burden of catastrophic costs incurred by individuals undergoing TB treatment and identified the main drivers of costs to aid in developing mitigation strategies. A literature search was performed in August 2024 using Embase, Web of Science, Scopus and Medline targeting studies using WHO, or WHO adapted patient costing questionnaires to measure direct (medical and non-medical) and indirect costs associated with TB care. Key cost data and patient baseline characteristics were extracted. The study protocol was registered in PROSPERO (Registration number: CRD42021293600). The systematic review included 76 studies; with 70% published over the last 5 years. Total mean costs per person for TB care ranged from $7.13 - $11,329 USD; pre-diagnostic costs ranged from $30.37 - $1,442 USD; and post-diagnostic costs ranged from $33.64 - $5,194 USD. Costs were consistently higher amongst persons with drug resistant TB (DR-TB) and those identified through passive case finding (PCF). Hospitalization and loss of income were the largest drivers of cost. Despite many countries offering free TB treatment, patients still incurred significant catastrophic costs. Our review suggests that active case finding, improving access to DR-TB testing, and adopting social protection interventions may help mitigate the burden of out-of-pocket expenditures incurred by people suffering with TB.
Abstract
Evidence before this study:
Economic evidence examining patient costs incurred during TB treatment has previously been limited; however, following the release of the WHO “End TB Strategy” goals, there has been a rapid explosion of literature in this space. A handful of systematic reviews on the burden on catastrophic costs for TB patients have been conducted previously but they have restricted their analysis to particular geographical settings, patient populations or phases of TB care. We found no systematic review which examined the burden of these costs for patients in all stages of TB care across differing geographical settings and amongst different patient populations.
Added value of this study:
Our study demonstrated that despite countries offering free or subsidized TB care to their citizens, patients and their families still incurred significant catastrophic costs with many individuals resorting to coping strategies to manage the cost of care. Patients incurred a significant burden of costs throughout all stages of TB care with post-diagnostic medical components, including hospitalization and non-TB medications, having the largest impact. In addition, costs were consistently higher amongst patients with DR-TB and those who were identified using passive case finding (PCF) methods suggesting that delayed diagnosis can influence both patient outcomes as well as the burden of costs incurred during care.
Implications of all the available evidence:
The evidence derived from this study highlights the need for increased use of active case finding to promote early detection and diagnosis of TB, improved access to drug resistance testing, and timely access to treatment. Our study found that post diagnostic medical costs continue to have a large influence on patient costs. This finding highlights the importance of financial mitigation strategies for clients after they are diagnosed and engaged in care.
Citation: D’Silva OA, Lancione S, Ananthakrishnan O, Addae A, Shrestha S, Alsdurf H, et al. (2025) The catastrophic cost of TB care: Understanding costs incurred by individuals undergoing TB care in low-, middle-, and high-income settings – A systematic review. PLOS Glob Public Health 5(4): e0004283. https://doi.org/10.1371/journal.pgph.0004283
Editor: Bashar Haruna Gulumbe,, Federal University Birnin Kebbi, NIGERIA
Received: October 25, 2024; Accepted: January 26, 2025; Published: April 2, 2025
Copyright: © 2025 D’Silva et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
In 2022, tuberculosis (TB) was the second leading infectious cause of mortality, following COVID-191. The WHO reports that 50% of individuals impacted by TB incur catastrophic patient costs, defined as the total cost of TB care exceeding 20% of a household’s annual income pre-TB diagnosis[1]. The End TB Strategy developed by the WHO has as a central aim the goal to eliminate the burden of catastrophic costs for TB patients and their households by 2030[2]. But in order to achieve this goal we must have a clear understanding of how and where in the diagnostic and treatment pathways clients incur significant costs.
Patient costs can be incurred at any stage of treatment, pre-diagnostic or post-diagnostic, through direct medical costs such as consultations by medical professionals, diagnostic testing or medications, and direct non-medical costs such as transportation, accommodations and food. Indirect costs resulting from time lost during illness and loss of income while seeking care can also be significant[1,3,4]. For many, the cost burden catastrophically impacts their overall household income resulting in significant financial as well as social consequences. The financial burden associated with TB care has been found to deter individuals from seeking care and can lead to delayed diagnosis, poor adherence, and worsened TB outcomes[5,6]. While many countries offer free TB diagnosis and treatment through public health systems, patients and households with TB still incur severe costs associated with care[3,7].
Prior to 2015, economic evidence on patient costs associated with TB care was sparse. Since then, WHO has supported numerous national surveys to better understand the burden of patient-incurred costs. This coupled with the “Tuberculosis Patient Cost Surveys: A Handbook”, from WHO provides a standardized method for assessing TB patient costs[1,7,8]. Previous systematic reviews found that a large proportion of patients incur catastrophic costs while receiving TB care. Key populations— patients with drug-resistant TB (DR-TB) or human immunodeficiency virus (HIV), typically bear a higher burden of costs[3,4]. Yet these studies have not provided a detailed understanding of the costs associated with TB care or factors influencing these costs. Research examining direct and indirect costs incurred throughout all stages of care is limited. To our knowledge, no systematic review to date has reported on patient costs incurred during all stages of TB-care, across all global socioeconomic settings, with prior reviews restricted to analyses of catastrophic costs at specific stages of treatment, specific geographic regions, or among key population settings[3,4,9]. Thus, we conducted a systematic review to help broaden the current understanding of catastrophic costs by examining all costs incurred by patients during TB care in low-, middle-, and high-income country settings. Key costing data from the included studies was categorized as direct medical, direct non-medical, and indirect cost components, and main cost drivers were identified.
Methods
A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to understand the burden of costs for TB patients. Literature searches were performed in August 2024 in Embase, Scopus, Medline, and Web of Science databases. The studies that were included were published between 2011 and 2024. The search strategy contained no restrictions on language, or geography (S1 Text).
Inclusion criteria
Inclusion criteria consisted of primary research studies that collected and reported on TB patient-incurred costs using a WHO-approved or WHO-adapted patient costing survey (WHO – Tuberculosis Patient Costing Surveys: A Handbook, StopTB, USAID or the TB|CTA – Tool to Estimate Patient Costs) to collect costs[8,10,11]. We included patient populations with latent tuberculosis infection (LTBI), active TB disease, DR-TB, or multi-drug-resistant TB (MDR-TB) as well as with HIV-associated TB.
Exclusion criteria
Studies were excluded if they used a unique costing survey not based on the WHO approach or if they did not report patient costs. Abstracts, conference posters, letters, and systematic reviews were also excluded.
Studies were independently evaluated for inclusion by two reviewers (OD and SL). Discrepancies were resolved by discussion and consensus or by a third reviewer (AZ) where necessary. References from systematic reviews were examined to identify additional studies for inclusion. Included studies are shown in Fig 1 with detailed reasons for exclusions[12]. Key study and patient characteristics and costing data were independently extracted in duplicate by three reviewers (OD, SL, and OA) with discrepancies resolved by discussion. Reporting quality assessment of studies was done using an adapted CHEERS checklist (S1 Checklist).
It highlights the three main sections of the literature search – the identification phase, the screening phase and the inclusion phase. In addition, it also shows the number of studies that were excluded and their exclusion reasons as well as the number of additional records that were identified through examination of grey literature and added in to the review.
The primary study outcome was the total cost incurred by TB patients. Pre- and post-diagnostic costs were obtained and stratified by direct medical, direct non-medical, and indirect costs. Key cost components are listed and defined in the Appendix (S1 Table). The secondary outcome was the proportion of patients suffering from catastrophic costs based on the WHO definition. All costs were reported in 2023 USD using World Bank inflation and currency data. If there was missing data such as the year of cost valuation or original currency, reviewers would first attempt to contact the authors for clarification on the matter. If the information could not be confirmed with study authors, it was assumed that costs were collected in the local currency of the country where the study was conducted and valued at the final year of study. We reported both mean and median costs depending on how costs were reported which varied across studies. We also reported the average total cost of TB care across countries by calculating the average total costs reported in each study by country. Overall and individual cost components for direct medical, direct non-medical and indirect costs were compared across geographic settings, patient demographics, treatment stages, and economic standings to understand the burden across different groups as well as identify main drivers of costs.
Weighted averages were calculated by compiling reported patient costs for each subgroup, dividing the cost by patient population size and summing the costs together. Since costs were reported differently across studies both weighted mean and weighted medians were calculated for each sub-group of interest. These were used to understand the differences in patient costs across various subgroups including TB types (DS-TB vs DR/MDR-TB vs TB/HIV coinfection), geographic setting (WHO regions – African Region (AFRO), Eastern Mediterranean Region (EMRO), South-East Asia Region (SEARO), Western Pacific Region (WPRO), European Region (EURO), and the Pan American Health Organization (PAHO)), and TB burden settings (low-TB vs high-TB). TB burden settings were defined using the WHO Global List of High Burden Countries for Tuberculosis (TB), TB/HIV and multidrug/rifampicin-resistant TB (MDR/RR-TB), 2021 – 2025[13].
This study has been registered in PROSPERO (Registration number: CRD42021293600).
Results
PRISMA
Our search identified 1,334 studies, with an additional 25 articles found through manual searches. After 931 duplicates were removed, title and abstracts for 428 studies were reviewed, with 287 studies identified for full text reviews. Two studies were excluded due to no members of our team speaking the language in which they were published (Spanish). The remaining 285 studies underwent full-text review, and 76 studies were included in this review (Fig 1) [14–89].
Study characteristics
Key study characteristics for the included studies are outlined in Table 1. Of the 76 studies, 53 (70%) were published within the last five years (2019 – 2024) (S1 Fig) with all studies but one conducted in low- or middle-income countries based on World Bank Country classifications. Studies were conducted across rural and urban settings with a large proportion conducted in Asian (47.4%) and African countries (37.2%) (S2 Fig). Study populations consisted mostly of adult patients; 9 studies reported data on children <15 years of age, 36 studies (61%) included patients with HIV and 1 study included patients with diabetes. A total of 32 studies (42%) included patients with DR-TB or MDR-TB and only 1 study included patients with LTBI (1%). Where reported studies were conducted in either public health care settings (n=39), or a combination of public and private health care settings (n=31) (Table 1).
Fig 2A and when stratified by patient type as represented in Fig 2B. Fig 2A has the mean and median total average cost of TB care and reflects the differences in costs for patients who have DS-TB compared to patients with DR/MDR-TB. Fig 2B also presented the mean and median total average cost of TB care but instead reflects the difference in costs for differing subgroups of patient types including patients identified using ACF and PCF methods, patients in private and public health settings, inpatients and outpatients, initial and retreatment TB patients as well as patients with TB/HIV co-infection.
Total patient costs
Total patient costs were reported in 60 studies (S2 Table). Total cost per person for DS-TB patients ranged from a mean of $7.13 to $4,161 and a median of $7.00 to $2,443. In contrast, DR-TB total patient costs were considerably higher ranging from a mean of $3,075 to $11,329 and a median of $342 to $7,714.
When comparing the average total cost of TB care (Fig 2A), DR-TB patients incurred the largest burden of costs (mean: $3,617, median: $3,003) compared to DS-TB patients (mean: $1,083, median: $579). The weighted total mean cost for DR-TB patients was $8,947, and the weighted median was $3,799, while the weighted total mean for DS-TB was $1,259, with a weighted median of $187.
In patients with DS-TB, cost ranges for differing patient populations, such as PLHIV, inpatients versus outpatients, and patients identified using different case finding methods like ACF compared to PCF were examined and are highlighted in Fig 2B. Average total costs of TB care were highest in initial TB patients (mean: $112, median:$ 1,034), and patients with HIV-associated TB (mean: $808, median: $833). Patients coming in for TB re-treatment were found to have lower costs compared to initial TB patients (mean: $249, median: $492). Patients identified via PCF methods (mean: $783, median: $664) had higher costs compared to patients identified using ACF methods (mean: $584, median: $381). Insignificant differences were seen when comparing the average cost of TB care between other patient subgroups.
Pre-diagnostic patient costs
Total costs of pre-diagnostic care for patients were reported in 18 studies. Pre -diagnostic costs were relatively similar for MDR-TB patients (median $30.06 to $134) compared with DS-TB patients (median $7.30 to $168). Pre-diagnostic costs were divided into direct medical costs, direct non-medical costs, and indirect costs (Table 2). Medical costs were slightly higher than non-medical costs, ranging from a mean of $1.65 to $1,909 and a median of $7.61 to $113 (S2 Table). Consistent with earlier findings, direct medical costs were highest for patients with DR-TB, (mean: $1.65-$681, median: $8.42-$113) compared to DS-TB patients (mean: $3.42-$176, median: $8.11-$63.63). When summarized across studies weighted medians for DR-TB were $94.87, and among DS-TB a weighted median of $36.67 and weighted mean of $392.88 (Table 3). Factors that had the largest impact on the direct medical costs’ patients incurred during the pre-diagnostic phase were medications, diagnostic imaging and hospitalization. These cost components were highest for inpatients, patients with DR-TB and those identified using PCF methods.
Non-medical costs ranged from a mean of $3.60 to $725 and a median of $0.88 to $63.63 (S3 Table). Major contributors to non-medical costs were nutritional supplements, food, and transportation. Patients with DR-TB and those identified via PCF methods incurred higher non-medical costs except for food costs where DS-TB patients had slightly higher costs than DR-TB patients.
Indirect costs made up the largest portion of pre-diagnostic costs incurred by patients ranging from a mean of $1.26 to $271 and a median of $0.34 to $2,837 (S4 Table), with loss of income being largest single cost contributor (mean: $0.61-$611, median: $0.43-$2,837).
Post-diagnostic patient costs
Total post-diagnostic costs incurred by patients were reported in 21 studies. For DS-TB patients median post diagnostic costs ranged from $33.12 to $1,889. For DR-TB patients, post-diagnostic costs ranged from a median of $975 to $5,194, with a weighted median of $1,619. Among DS-TB, a weighted median of $63.01 and weighted mean of $680 was estimated (Table 3).
Direct medical costs were the largest component costs, they ranged from a mean of $0.03 to $17,140 while median costs ranged from $5.16 to $14,093 (Table 4). Cost factors that had the biggest impact on medical costs included medication, follow-up tests and hospitalization. Medical costs were highest amongst DR-TB patients (S5 Table).
Non-medical costs ranged from a mean of $7.60 to $8,649 while median costs ranged from $1.41 to $520 (S6 Table). Key factors that impacted non-medical cost burden were food, transportation, and nutritional supports. MDR-TB patients consistently incurred the largest burden of non-medical costs except in the 2020 study by Chittamany et al., where DS-TB patients incurred greater costs than DR-TB patients (median: DS-TB: $520, DR-TB: $423)[23].
Indirect costs ranged from a mean of $1.26 to $6,045 while median costs ranged from $1.57 to $2,837 (S7 Table). Loss of time was the largest component cost contributing to overall lost income (mean $0.18 to $6,045, median $0.69 to $950). Indirect costs were highest amongst DR-TB patients (mean: $51.46-$6,045, median: $80.89-$2,837).
Patient cost variation by geographical region
Across WHO regions, weighted total costs were highest in DR-TB patients from the WPRO region with a median of $8,774 and a mean of $8,481 (Table 5). Pre-diagnostic and post-diagnostic weighted medians could only be calculated for two WHO regions in DR-TB patients – AFRO and SEARO. Weighted medians for both stages were higher in the AFRO region and lower in the SEARO region (pre-diagnostic: $104 versus $14.88; post-diagnostic: $1,619 versus $746). Weighted means for the pre- and post-diagnostic stages could not be calculated due to insufficient data.
In high TB burden settings, weighted medians for total costs incurred by DR-TB patients were identical in high TB and MDR-TB burden settings ($8,774) while means were higher in high MDR-TB burden settings compared to high TB/HIV burden settings ($4,184 versus $2,853). For pre-diagnostic and post-diagnostic stages, weighted medians were highest in high TB burden settings and lowest in high MDR-TB settings.
In low TB burden settings, medians for total costs incurred by DR-TB patients were highest in low TB/HIV burden settings compared to low MDR-TB burden settings ($3,568 versus $1,722). Weighted medians for pre-diagnostic costs were only able to be calculated for low MDR-TB settings. Post-diagnostic costs were highest in low MDR-TB settings and identical for both low DS-TB and low TB/HIV settings ($1,619 versus $1,110). Weighted means for low TB burden settings could not be obtained due to insufficient data.
Total costs of care for DS-TB patients were highest in the WPRO region (median: $1,190, mean: $1,709) (Table 6). Median weighted averages for pre- and post-diagnostic stages varied between regions while mean weighted averages were consistently higher in the WPRO region for both stages (mean pre-diagnostic: $353, post-diagnostic: $1,059).
Catastrophic costs
Based on the WHO definition, the proportion of patients that incurred catastrophic costs while seeking care ranged from 3% to 98% (Table 7) with MDR-TB patients reporting a higher burden of catastrophic costs (62-98%) compared with DS-TB patients (28-62%). In addition, patients identified via ACF reported a lower burden of catastrophic costs compared to patients identified via PCF, (15-45% versus 30-61%).
To help offset the costs of TB care, patients who suffered from catastrophic costs reported using coping strategies such as: borrowing money (reported in n=33 studies, range: 0-94%), selling assets (n=27, range: 0-52%), using savings (n=11, range: 10-40%), or a combination of strategies (n=10, range: 12-81%) (S8 Table).
Risk of bias reporting checklist
A risk of bias quality assessment was done on all included studies using an adapted CHEERS checklist, results are displayed in Fig 3, studies scored from 55-96% on the reporting checklist. Overall, studies included in this review were found to be of high quality with 63% of studies (n=48/76) scoring above 70% of checklist items indicating a low risk of bias. There were some key areas of concern, including missing information on currency used, price data, and conversion information, as well as information pertaining to analytical methods, and sensitivity analysis.
This figure highlights the key checklist criteria categories for the adapted checklist and reflects the number of studies that meet the criteria (blue), don’t meet the criteria (red), or where the criteria was not applicable.
Discussion
Eliminating the burden of catastrophic costs experienced by individuals combatting TB is one of the WHO End TB Strategy targets, this systematic review summarized current evidence from 76 studies published from 2011 to 2024 regarding the costs incurred by individuals diagnosed with and receiving TB treatment and identified main drivers of costs to inform mitigation strategies.
A surge in research in the last five years has led to an increase in TB costing studies conducted across a range of patient populations in low-, middle-, and high-income settings. Total TB care costs ranged widely however, when analyzed based on TB type it was found that DR-TB patients incurred considerably higher costs compared to DS-TB patients. This was consistently seen when examining the average total cost of TB care as well as the weighted total mean/median cost of TB care. In patients with DS-TB, there was also a large stratification across differing patient populations. Analysis of the average total costs of TB care for DS-TB patients found that costs were highest in initial TB patients, patients identified using PCF, and PLHIV despite this review identifying limited cost data for PLHIV [25–29].
Overall, direct medical and indirect costs were the main drivers of financial burden for patients. Direct medical costs including patient consultations, medication, diagnostic imaging, and hospitalization, in addition to indirect costs, namely loss of income were the largest component costs. Pre-diagnostic costs were found to be lower than post-diagnostic costs, despite previous literature finding that patients incurred a larger burden of costs during the pre-diagnostic stage[3,90]. When analyzed based on patient type, little difference in pre-diagnostic costs was seen between DR-TB and DS-TB patients. During the pre-diagnostic stage, indirect costs and direct medical costs had the largest burden on patients. Post-diagnostic costs saw DR-TB patients incurring a larger burden compared to DS-TB patients and once again, direct medical costs and indirect costs had the largest impact on patients. Our findings support previous literature that income loss is one of many factors that poses a significant financial risk for patients and their families while receiving TB care[3,91]. Supporting individuals throughout their TB treatment either through basic income support or cash transfers may be an important element in ensuring individuals can complete treatment and do not face further financial hardship.
Despite similarities between study populations and settings, there were large variations in patient-incurred costs. For DS-TB and DR-TB patients, weighted total costs were highest in WPRO countries including Cambodia, China, Lao People’s Democratic Republic, the Philippines and Viet Nam[92]. As expected, due to the complicated nature of DR-TB, weighted averages were highest in countries with high MDR-TB burden like China, India, and Vietnam where patients often incur a larger burden of costs associated with medication, severe adverse events and challenges with treatment adherence[93–95]. Financial compensation strategies like unconditional or conditional (e.g., for patients with specific types of TB) cash transfers, have shown promising results for reducing the costs burden, although additional data is needed[4,96,97]. “One-size-fits-all” health care policies fall short when it comes to TB care. Countries must adopt tailored policies that provide support and care to their most vulnerable populations [88,98].
The findings of this review highlighted some key patient subgroups of interest for further analysis, Evidence shows that PLHIV had some of the lowest weighted averages, despite previous literature predicting that these individuals may suffer additional financial burdens associated with HIV care, more data on patient level costs among PLHIV is warranted in helping to understand the interplay between costs incurred during TB and HIV care and how catastrophic costs could be mitigated in this group [29,57,70,99,100]. Persons diagnosed with DR-TB, receiving their initial dose of treatment, or identified through PCF consistently incurred larger burden of costs compared to other subgroups, likely due to requirements of longer treatment, longer hospitalizations, more complicated treatment regimens, and higher risk of severe adverse events[101]. ACF is an effective tool to promote earlier TB case detection, and may not only lead to improved patient outcomes, and potentially reduce ongoing community transmission but our review suggests it may also serve to reduce the burden of costs patients incur due to delayed TB diagnosis and lengthier treatment trajectories. In addition, the inclusion of novel, shortened treatment regimens can help to reduce the duration of treatment for both DS-TB and DR-TB patients and as a result, limit the burden of costs that these individuals and their families may face. Studies have found that bedaquiline, pretomanid, and linezolid (BPaL) based regimens are considered to be more effective than the current standard of care for TB treatment and are most cost effective for both individuals as well as the health system[102–104].
Most individuals were found to incur catastrophic costs while receiving TB care. Catastrophic costs were consistently higher in patients with MDR-TB or identified via PCF. These catastrophic costs lead patients to use coping mechanisms such as taking out loans, selling assets or using their savings to help offset some of the financial burden of TB care, leading to significant social consequences such as job loss, interrupted work or schooling, and food insecurity and may impact relationships and result in social exclusion [16,61,69,105]. These factors can isolate individuals from their community and further perpetuate poverty, such that patients may hesitate to seek care to limit these consequences, thereby increasing TB transmission[106–108]. Patients who incur catastrophic costs are 2-4 times more likely to experience treatment failure [34], therefore mitigating these costs will not only benefit individuals but also the health systems and communities at large. ACF programs coupled with improved access to DST such as targeted next generation sequencing could have an important impact on reducing catastrophic costs.
Study strengths and limitations
There are several strengths to this review; including use of a comprehensive search strategy encompassing studies with differing patient and geographical populations over a large time frame and considered all income level country settings allowing us to compile and compare an extensive range of data. One key limitation is that we restricted to studies that collected patient costing data using WHO or WHO-adapted patient costing surveys. This precluded studies that were conducted prior to the development of the costing survey and studies that did not use the WHO patient costing survey from inclusion, however this approach allowed for improved comparability across included studies. Another key limitation of this study is that some studies conducted after 2019 were restricted in their data collection due to the COVID-19 pandemic and due to the global impact of this pandemic, patients reported suffering from higher cost burdens. As a result, the costs estimated for these studies may not accurately represent the burden of costs that patients in these regions incur outside of the pandemic.
Conclusion
The findings of this review have demonstrated that “free” TB care under national TB programs is not adequate to prevent patients from facing severe financial burdens during TB diagnosis and treatment. Throughout all stages of care, patients incur costs which vary largely based on patient type and geographical location. These costs can be catastrophic, resulting in the use of various coping mechanisms. Complementary social protection and financial support policies and systems should be further developed and implemented alongside standard TB care programs to protect TB patients from financial burden. Furthermore, uptake of practices like active case finding and more effective treatment regimens like BPaL can help to identify and treat individuals in a cost-savings, timely manner. By working to understand the factors that influence patient costs, we can develop tailored social protection strategies and policies that provide effective TB care resources while lowering catastrophic costs for patients in accordance with the WHO “End TB Strategy” goals[98,109].
Supporting information
S1 File. Studies screened with exclusion reasons.
https://doi.org/10.1371/journal.pgph.0004283.s003
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S1 Fig. Temporal breakdown of included studies.
https://doi.org/10.1371/journal.pgph.0004283.s005
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S2 Fig. Geographical breakdown of included studies.
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S3 Fig. Average total cost of TB care by country (mean, median).
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S2 Table. Breakdown of direct medical costs incurred by patients during the pre-diagnostic phase.
https://doi.org/10.1371/journal.pgph.0004283.s008
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S3 Table. Breakdown of direct non-medical costs incurred by patients during the pre-diagnostic phase.
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S4 Table. Breakdown of indirect costs incurred by patients during the pre-diagnostic phase.
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S5 Table. Breakdown of direct medical cost incurred by patients during the post-diagnostic phase.
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S6 Table. Breakdown of direct non-medical costs incurred by patients during the post-diagnostic phase.
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S7 Table. Breakdown of indirect costs incurred by patients during the post-diagnostic phase.
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S8 Table. Use of coping strategies in the included studies.
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