The TB - poverty cycle : dynamics, determinants, and consequences of economic hardship faced by people with TB in Mozambique

Background:

Tuberculosis (TB) remains a significant global public health challenge characterised by a high incidence rate, association with HIV and socioeconomic impacts on affected people, their households and communities. The notification numbers for all forms of TB have been rising in Mozambique, challenging the already fragmented health systems to provide quality healthcare with efficient diagnosis, treatment, and follow-up. Knowledge about how people with symptoms seek care and the challenges associated with healthcare-seeking and treatment, including incurred costs and the prevalence of catastrophic costs, is still scarce in Mozambique.

Aim:

To understand the dynamics, determinants and consequences of economic hardship of people with TB and their households in Mozambique and to identify appropriate interventions to minimise and mitigate the costs they face.

Methods:

We used a multi-methods design, including quantitative data from the TB Sequel cohort study (a cohort of adult people with pulmonary TB) initiating TB treatment between December 2017 and January 2020, alongside qualitative interviews as part of the CHEST study conducted from 2019 to 2022. The quantitative component used an adapted version of the World Health Organization's generic TB patient cost survey tool to assess healthcare-seeking patterns, treatment initiation pathways, and associated costs. Data were summarised using descriptive statistics and logistic regression models to identify factors associated with the number of pre-treatment healthcare visits and the occurrence of catastrophic costs. The qualitative component used semi-structured, in-depth interviews with people with pulmonary TB and policymakers in the health and social protection sectors. Data were analysed using reflexive thematic analysis to explore the lived experiences of people with TB and content analysis to explore the policymakers' perspectives on potential solutions for socioeconomic impact and intersectoral collaboration.

Results:

The quantitative component enrolled 417 participants. Nearly two-thirds sought care from multiple healthcare providers, resulting in a mean time of 7.7 (SD=5.5) weeks from symptom onset to treatment initiation. The mean total cost incurred from symptoms onset up to treatment initiation was $102.2 (SD=203.9), increasing to $413.8 (SD=792.3) by treatment completion. Approximately 46% (95% CI: 37.9 - 54.4) of participants experienced catastrophic costs. In the qualitative component, we found that TB's social and economic impacts require resourcefulness at the family and community levels. The need for social protection varied according to the individual's priorities. Policymakers highlighted the lack of explicit inclusion criteria for people with TB in the existing social protection policies and identified resource limitations as barriers to implementing effective strategies to mitigate socioeconomic hardship.

Conclusion:

While people with TB had proactive healthcare-seeking behaviour, barriers within the health system, including encounters with private sector healthcare providers, might contribute to significant treatment delays, posing significant social and economic burdens. The results underscore the urgent need for health services improvements and the development of inclusive social protection frameworks that consider the needs of TB-affected households. Moreover, fostering intersectoral collaboration between health and social protection sectors is essential to creating comprehensive strategies to alleviate the socioeconomic impacts of TB in Mozambique.

Keywords: Tuberculosis, healthcare-seeking, treatment initiation, economic burden, social protection, intersectoral collaboration, Mozambique

List of scientific papers

I. Mapping treatment initiation pathways and associated costs among people with pulmonary tuberculosis in a peri- urban area of Mozambique: A cross-sectional study. Pedroso Nhassengo, Salla Atkins, Celina Nhamuave, Miguel Uanela, Cristovão Matusse, Denise Banze, Vânia Maphossa, Kamban Hirasen, Olena Ivanova, Denise Evans, Knut Lönnroth, Celso Khosa, Tom Wingfield. [Submitted]

II. Estimating the prevalence of catastrophic costs before and during treatment of adults with tuberculosis in Mozambique. Pedroso Nhassengo, Salla Atkins, Denise Evans, Olena Ivanova, Miguel Uanela, Denise Banze, Celina Nhamuave, Kamban Hirasen, Knut Lönnroth, Celso Khosa, Tom Wingfield. [Manuscript]

III. "They didn't look at me with good eyes" - Experiences of the socioeconomic impact of tuberculosis and support needs among adults in a semi-rural area in Mozambique: A Qualitative Study. Pedroso Nhassengo, Clara Yoshino, Américo Zandamel, Verónica De Carmo, Bo Burström, Knut Lönnroth, Tom Wingfield, Celso Khosa, Salla Atkins. Global Public Health. 2024 VOL. 19, NO. 1, 2311682. https://doi.org/10.1080/17441692.2024.2311682

IV. Perspectives of healthcare and social support sector policymakers on potential solutions to mitigate financial impact among people with TB in Mozambique: a qualitative study. Pedroso Nhassengo, Clara Yoshino, Américo Zandamela, Verónica De Carmo, Bo Burström, Celso Khosa, Tom Wingfield, Knut Lonnroth, Salla Atkins. BMJ Open. 2023;13:e073234. https://doi.org/10.1136/bmjopen-2023-073234