Catastrophic Costs and Impoverishment Among Tuberculosis-Affected Households in Nepal: Results from a National Patient Cost Survey

Abstract Tuberculosis (TB) poses a significant economic burden on affected households. Despite the provision of free diagnosis and treatment services, patients and their households experience substantial financial hardship. This study aimed to estimate the catastrophic costs faced by TB patients in Nepal and identify associated factors. We conducted the first national cross-sectional survey of 1000 patients enrolled within the National Tuberculosis Program (NTP). The sample consisted of 600 drug-susceptible (DS-TB) and 400 drug-resistant TB (DR-TB) patients. Data were collected through structured interviews using the standardized TB patient cost survey questionnaire. Costs were categorized as direct medical, direct non-medical, and indirect. Indirect costs were estimated using the human capital approach. Catastrophic total costs due to TB was defined as total TB-related costs exceeding 20% of annual pre-TB household income. The mean age of participants was 43 years, and 65% were male. Forty-two percent of participants engaged in informal paid work and 70% had not completed secondary education. One-third of the participants reported having some form of social protection, with just 11% possessing health insurance coverage. Overall, 51% of TB-affected households faced catastrophic costs due to TB, with a higher proportion among DR-TB patients (76%) compared to DS-TB patients (51%). The financial burden was primarily driven by direct non-medical costs (44%) and indirect costs (39%), substantially exceeding direct medical costs (17%). Factors associated with catastrophic total costs included belonging to a poorer wealth quintile, a DR-TB diagnosis, being the primary income earner, and lacking health insurance coverage. TB-related costs pushed 13% of households below the poverty line, increasing to 31% among DR-TB households. Mitigating this burden requires an integrated approach that aligns early diagnostic interventions with comprehensive social protection. Specifically, combining direct cash transfers for wage replacement with in-kind nutritional support is critical to protect high-risk households and reduce non-medical financial shocks.