Households of Tuberculosis (TB) patients face high TB-related costs: Somalia Experience

Background Tuberculosis (TB) services are seemingly free in Somalia, but patients still incur high costs to access TB diagnosis, treatment, and care. This study is the first for Somalia. It estimated the proportion of TB-affected households experiencing catastrophic costs among TB patients and their households in Somalia, including identifying the risk factors and major patient cost drivers and describing the coping strategies they adopt to cushion its effect. Method A prospective cluster-sampled cross-sectional survey, nationally representative with retrospective data collection, was conducted among patients in TB care (drug-susceptible TB [DS-TB] and drug-resistant TB [DR-TB]) within the Somalia national TB network. The design was guided by the World Health Organization’s Handbook on National TB Patient Cost surveys and collected data on patients’ socio-demographic and clinical characteristics, including a model of care, self-reported income and expenses, costs (out-of-pocket expenses and indirect) for one episode of TB, risk factors for incurring cost and dissaving mechanisms. All costs were collected and reported in USD. Result The percentage of TB-affected households facing costs > 20% of household income was 68% (95% CI: 64% – 71%) in Somalia in 2023 and 69% (95% CI: 65% – 73%) and 62% (95% CI: 52% – 71%) amongst patients on first and second-line drug treatment respectively. Monthly self-reported household income reduced by 43% from $176 before contracting TB to $101 at the time of the interview, with 75.4% (364) of households who suffered TB-related catastrophic costs reporting that they became poorer accessing TB services. To be able to access TB treatment and care services and cope with the economic burden of TB-related catastrophic costs, 42% (375) of TB patients and their households adopted one or more dissaving strategies in the form of loans or the sale of assets. The odds of facing TB-related catastrophic costs were highest among TB patients residing in the Southwest state. Conclusion This study found that almost three out of four patients in TB care and their households experience a substantive financial burden accessing TB services in Somalia, particularly during the continuation phase of their treatment, and mainly driven by the direct non-medical costs. A sustainable and equitable social protection program is required to reduce the proportion of households facing financial burdens due to TB in Somalia.