Despite free medicines under India’s TB control programme, patients with drug-sensitive pulmonary tuberculosis can still face a substantial financial burden, with lost income and the cost of diagnosis accounting for a significant share of their overall expenditure, a systematic review has found.
An analysis of 21 Indian studies published between 2014 and 2024 estimated the average cost of TB care at ₹20,674 per patient. Nearly two-thirds of this, about ₹12,767, was attributed to indirect costs such as lost wages and reduced productivity, while direct medical expenses averaged ₹6,952.
The study, published in the Indian Journal of Tuberculosis, found that around 15 per cent of households affected by drug-sensitive pulmonary TB incurred catastrophic health expenditure, defined as spending more than 20 per cent of household income on TB care.
Dr Aviraj KS, one of the researchers involved in the meta-analysis, said the findings showed that the financial impact of TB extends well beyond the cost of medicines.
“Even though the medical cost has reduced, what is hidden or not being seen is the cost beyond the medical treatment, which is the income of the patient, the productivity of the patient,” he said.
Lost Wages
Indirect costs emerged as the largest component of the financial burden. These included income lost because patients were unable to work during illness and treatment, as well as reduced productivity.
Aviraj said the burden could be particularly severe for people dependent on daily wages, with TB-related stigma potentially affecting their ability to retain employment.
“Due to the stigma, they are removed from the jobs, from the wages, daily wages,” he said.
TB treatment can last at least six months, he noted, leaving patients vulnerable to prolonged income loss.
The study also examined whether the National Tuberculosis Elimination Programme (NTEP), which replaced the earlier Revised National Tuberculosis Control Programme (RNTCP), had reduced the financial burden on patients.
The findings were mixed. Direct medical and non-medical expenditure declined after the introduction of NTEP, suggesting that free medicines and other government support helped reduce some out-of-pocket costs. However, indirect costs, including income lost because of illness and treatment, as well as diagnostic expenditure, increased.
Consequently, the average overall cost of TB care rose slightly from around ₹20,263 before NTEP to ₹21,301 after its introduction.
Private Care
Aviraj said one reason patients continue to incur significant expenditure is that many first seek treatment in the private sector, despite the availability of free services through the government programme.
“Although the government is giving free facility and everything, the first approach of the patient is always the private doctor, the private clinicians. There, there occurs a lot of expenditure,” he said.
The financial consequences can extend beyond the individual patient to the entire household. According to Aviraj, the analysis showed that more than 20 per cent of household income could be spent on TB-related care in some cases.
“This is reducing the quality of life and putting a lot of burden on the family,” he said.
The researchers therefore argue that providing free medicines alone may not be sufficient to prevent financial hardship among TB-affected households. Patients can continue to incur costs because they are unable to work during illness and treatment or have to pay for diagnosis, particularly when they seek care outside the public health system.
Wider Support
Aviraj said government support should begin before patients reach public healthcare facilities by reducing the costs they incur while seeking initial care in the private sector.
“Government should work before the patient reaches the public healthcare structure,” he said.
He also called for support beyond free diagnostics, medicines and nutritional assistance, including measures to help patients return to work and regain their livelihoods.
“Rehabilitation or self-empowerment of these patients is very, very important,” he said. “TB is not just a medical issue. It is a socio-economic issue as well.”