Predicting tuberculosis patient costs through the care cascade in low- and middle-income countries: a systematic review and meta-analysis

Background Households affected by tuberculosis (TB) often incur substantial costs, despite efforts to make TB treatment affordable. Local estimates of household costs associated with TB diagnosis and treatment are critical for quantifying the burden faced by TB-affected households and the potential impact of proposed interventions. Methods We conducted a systematic review and meta-analysis of studies published during 2015-2024 that collected data on costs incurred by TB-affected households in a low- or middle-income country (LMIC) (PROSPERO CRD42025159307). We extracted cost estimates, stratified by care-cascade phase (pre-treatment, intensive treatment, and continuation treatment) and cost category (direct medical, direct non-medical, and indirect). We fit multi-level Bayesian meta-regression models predicting per-episode costs in 2025 International Dollars for all LMIC (including those not captured in review data). Covariates included country-year matched median household income, out-of-pocket percentage of current health expenditures, and TB case detection rates, plus study- and country- random effects. We also investigated temporal trends in costs. Results We identified 122 relevant studies, of which 104 were included in quantitative analysis. Included studies represented 55,623 participants across 38 countries, surveyed during 2009-2023. Estimated country-level, per-episode costs of rifampin-susceptible TB (RS-TB) ranged from $668 (95% credible interval: $196, $1,697) to $9,156 ($1,657, $31,476). Indirect and continuation treatment costs had the highest relative burden, representing 46% (IQR: 32%, 61%) and 41% (20%, 62%) of per-episode costs, respectively. Time trend estimates were small and insignificant for total TB costs [average annual increase 4.0% (95% credible interval: -4.0%, 12.0%)]. Interpretation TB-affected households still face high costs throughout the care-cascade. Costs varied across countries, category, and care phase; incorporating these differences into TB economic evaluations could improve the quantification of intervention benefits. Costs were relatively stable over time, suggesting continued efforts to reduce household economic burden of TB are needed. Funding Bill & Melinda Gates Foundation.