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Global Health Econ Sustain MDR-TB and the road ahead

(WHO, 2015). Despite initial progress, the reduction in the WHO has recommended ambulatory care models for
TB incidence and mortality has been modest, with only managing MDR-TB, as they preserve clinical outcomes,
an 11% decrease in incidence and a 9.2% decrease in improve access and compliance, and reduce costs by up
mortality observed between 2015 and 2020 (WHO, 2021). to 60% compared to inpatient stays, while also reducing
Moreover, the SARS-CoV-2 pandemic has exacerbated the cost per disability-adjusted life years (DALYs) by 54%
the situation, resulting in approximately 500,000 excess (Fitzpatrick & Floyd, 2012; WHO, 2014). Importantly,
TB deaths. By 2022, the gap between TB incidence and ambulatory models are scalable, as demonstrated in
disease notification had reached 3.1 million (WHO, 2023). Ethiopia. Between 2012 and 2015, the use of treatment and
Chronic underfunding contributes significantly to this follow-up centers achieved 1,211%, 1,969%, and 2,100%
underachievement. In 2019, only $6.8 billion USD out increases in the number of treatment centers, MDR-TB
of the required $13 billion USD annually was allocated sputa processed, and the number of patients enrolled,
to TB services and management. It is estimated that an achieving clinical cure in approximately 65% and only
additional $290 billion USD will be needed to achieve the an 8% loss to follow-up rate (Molla et al., 2017). With the
90% reduction goal by 2045, owing to the impact of the advent of digital healthcare, digital adherence technologies
SARS-CoV-2 pandemic (United Nations, 2018; Cox & may further assist with decentralized care model adoption
Furin, 2021). and allow the early identification of patients requiring
additional support, thereby improving clinical outcomes,
3.2. MDR-TB economics although this has yet to be formally studied (Subbaraman
When considering MDR-TB, both direct and indirect et al., 2018).
costs are influenced by the healthcare setting, In 2015, the WHO announced the goal of eliminating
geographical location, and disease prevalence. Alongside “catastrophic costs” in TB by 2030, defined as total costs
any reimbursements, they define total costs. Direct to the patient equal to or greater than 20% of the annual
medical costs encompass hospitalization, investigations, household income. The Global Tuberculosis Report (2023)
outpatient management (e.g., directly observed therapy), highlighted that 50% of TB patients and households face
and medication costs. In contrast, non-medical direct catastrophic costs, a situation exacerbated by the SARS-
costs include administration fees, transportation, CoV-2 pandemic (WHO, 2023). Risk factors for incurring
accommodation, and expenses for food supplementation, catastrophic costs include MDR-TB disease, HIV positivity,
such as micronutrients, which are often co-prescribed employment status, low education attainment, duration of
(Van den Hof et al., 2016; Tanimura et al., 2014; Grobler hospitalization, and baseline socioeconomic status (Ghazy
et al., 2016). Indirect costs, however, refer to those et al., 2022; Yang et al., 2020). Unsurprisingly, catastrophic
imposed on individuals by the disease process, such as costs are more prevalent in areas with lower economic
loss of employment, productivity, time, and income (Van classification (low- and middle-income countries 85.18%
den Hof et al., 2016). When considering their relative vs. upper-middle-income countries 70.66%), with HIV
contributions in the setting of DS-TB, non-direct medical prevalence significantly contributing to this difference
and indirect costs predominate both before and after TB (p = 0.000) (Akalu et al., 2023). Even in countries where
diagnosis (Tanimura et al., 2014). In MDR-TB, total costs TB medication and treatment are provided for free, 51 –
are significantly higher than in DS-TB; direct costs are 67% of patients still suffer catastrophic costs, adversely
the most significant due to the complexity of traditional affecting outcomes (Assefa et al., 2024; Ikram et al., 2020).
drug regimens, isolation requirements, and the need for The provision of reimbursements has been shown to
inpatient monitoring (Akalu et al., 2023). Moreover, in improve clinical cure rates, reduce loss to follow-up by
countries where mandatory hospitalization is required, tenfold, and achieve five-fold reductions in unfavorable
households may experience a 100% loss of income, treatment outcomes (Yu et al., 2018; Chen et al., 2022).
plunging them into poverty. In a review of MDR-TB in Therefore, means-tested reimbursement must be factored
16 countries, total costs were $83,365, $5284, $6,313, and into national TB programs alongside other forms of social
$1,218 USD in high-income countries, upper-middle- support to prevent families from falling into poverty. It is
income countries, lower-middle income countries, and estimated that abolishing extreme poverty (< $1.90 USD/
low-income countries, respectively (Laurence et al., day) would reduce the global incidence of TB by a third
2015). This difference in cost is achieved by lower drug and, when combined with social programs, by up to 84%
prices provided on compassionate grounds to developing (Carter et al., 2018). Social support measures, including
countries, including, most recently, bedaquiline and child benefits, national health insurance, improved housing,
the unavailability of inpatient resources (e.g., negative food vouchers, and monthly food baskets, have proven to
pressure rooms) (Stop TB Partnership, 2023). Since 2011, improve MDR-TB outcomes and reduce loss to follow-up

Volume 2 Issue 2 (2024) 3 https://doi.org/10.36922/ghes.2876