The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal
Suman Chandra Gurung, Kritika Dixit, Bhola Rai, Maxine Caws, Puskar Raj Paudel, Raghu Dhital, Shraddha Acharya, Gangaram Budhathoki, Deepak Malla, Jens W. Levy, Job van Rest, Knut Lönnroth, Kerri Viney, Andrew Ramsay, Tom Wingfield, Buddha Basnyat, Anil Thapa, Bertie Squire, Duolao Wang, Gokul Mishra, Kashim Shah, Anil Shrestha, Noemia Teixeira de Siqueira-Filha
Infectious Diseases of Poverty · 2019 · DOI: 10.1186/s40249-019-0603-z
Countries: Nepal
What Was Studied
This cross-sectional patient-costing study, conducted between June and August 2018 in Bardiya (Terai, high TB burden) and Pyuthan (hill, medium TB burden) districts under the Birat Nepal Medical Trust (BNMT) TB REACH Wave 5 project, compared costs incurred by 99 adult pulmonary TB patients: 50 diagnosed through active case finding (ACF — contact tracing, TB camps, and outpatient department screening using Xpert MTB/RIF) and 49 diagnosed through passive case finding (PCF, i.e. self-presentation at DOTS centres). Patients were interviewed 14-90 days into treatment using the WHO TB Patient Cost Tool, capturing direct medical, direct non-medical, and indirect (time/income loss) costs during the pre-treatment and intensive treatment phases. Catastrophic costs were defined per WHO methodology as total costs exceeding 20% of annual household income.
What They Found
ACF patients incurred substantially lower costs than PCF patients during the pre-treatment period: direct medical costs were USD 14 vs USD 32 (P=0.001), direct non-medical costs USD 3 vs USD 10 (P=0.004), and indirect time-loss costs USD 4 vs USD 13 (P<0.001). Across the combined pre-treatment and intensive-treatment phases, total direct costs were 65% lower for ACF patients (USD 40 vs USD 115, P=0.001). Using the WHO 20%-of-annual-income threshold and considering direct costs only, the prevalence of catastrophic costs was 61% lower among ACF patients (13% vs 33%, P=0.029); considering total (direct plus indirect) costs, prevalence was 45% for ACF versus 61% for PCF (a 26% relative reduction), with 69% lower intensity of catastrophic costs (53% vs 172%), though this difference was not statistically significant. PCF patients were also far more likely to report becoming 'much poorer' after starting TB treatment (20% vs 2% of ACF patients, P=0.016). Despite ACF's cost advantage, catastrophic costs remained very common in both groups: patients under 60 years diagnosed passively faced significantly higher odds of catastrophic costs than those diagnosed actively (OR 4.6, 95% CI 1.19-19.32).
What This Means for Nepal
These findings directly support the National TB Programme's (NTP) National Strategic Plan strategy of scaling up ACF — contact tracing, TB camps, and OPD-based Xpert screening — toward the End TB Strategy's target of zero TB-affected households facing catastrophic costs, a target Nepal has clearly not yet met given that catastrophic costs still affected 53% of all patients in this study. Three concrete actions follow: (1) the NTP and donor-funded projects (like BNMT's TB REACH) should prioritise expanding community-health-worker-led ACF into more of Nepal's high-burden districts, since ACF cut total direct costs by 65% and direct-cost catastrophic-cost prevalence by 61%, largely by removing the need for repeated transport and diagnostic visits; (2) because even 'free' NTP/DOTS treatment left households facing substantial non-medical (transport, food) and indirect (income/time loss) costs — the main drivers of catastrophic costs in both groups — Nepal needs a complementary social-protection instrument, such as a conditional cash or transport transfer for TB-affected households in high-burden Terai districts like Bardiya, rather than relying on free clinical services alone; (3) given the significantly higher odds of catastrophic costs among working-age (under-60) patients diagnosed passively (OR 4.6), a national TB patient-cost survey — as the authors recommend — should track catastrophic costs by age and district to target social-protection measures where financial hardship is most acute.
Contextualisation
Nepal's National TB Programme (NTP) provides free DOTS treatment, yet TB incidence remains high (229 per 100,000 in 2023, WHO Global TB Report 2025) and roughly half of estimated cases go unnotified — a gap partly attributed to financial and access barriers patients face before ever reaching a diagnosis. This study, conducted in two BNMT TB REACH districts (Bardiya and Pyuthan), is the first in Nepal to directly compare patient-incurred costs between active case finding (ACF) and passive case finding (PCF), providing evidence for the NTP's National Strategic Plan ambition to scale up ACF toward the End TB Strategy's milestone of zero TB-affected households facing catastrophic costs. With out-of-pocket spending already 54.2% of Nepal's current health expenditure (NHA 2019/20), the finding that even 'free' TB treatment produces catastrophic costs for a majority of affected households (53% overall) underscores why social protection, not clinical care alone, is essential to closing Nepal's TB financial-protection gap.