The Economic Burden of Tuberculosis and the Mitigation Effect of Social Protection: A Population-Based Study in Ghana

Background: Tuberculosis (TB), a major global public health concern, is known as a disease of the poor. However, evidence on the economic burden of TB is limited, and so is the literature on the impact of poverty alleviation strategies, such as social protection (SP), on financial protection for TB patients. This PhD aimed to contribute to the body of knowledge on the costs and affordability of TB care, and on the potential mitigation effect of SP on TB patient costs. Conceptual analyses and empirical data I collected as part of a nationally representative TB patient cost survey in Ghana were used to address these objectives: 1) Provide evidence on the level, and composition, of costs incurred by TB-affected households and affordability of TB care; 2) Investigate determinants of costs, and the impact of National Health Insurance (NHIS) on costs; 3) Explore the potential impact of costs on TB treatment outcomes. Results: This thesis showed that TB patients in Ghana face financial catastrophe and impoverishment due to the cost of TB care. The poorest and those with drug-resistant TB have increased odds of experiencing catastrophic costs. NHIS in its current form is not effective in defraying costs, and its expansion will not be effective to relieve the financial burden for TB-affected households. Further, this thesis did not find an effect of costs on treatment outcomes as, like most TB patient cost surveys, our study was not powered to detect such an association. Conclusion: SP schemes require enhancement if they are to protect TB patients from financial catastrophe. Evidence generated from this thesis provides original insights into affordability of TB care, lending weight to policy recommendations on financial protection for TB patients. This PhD also shows both the potential and limitations of TB patient cost surveys to assess the impact of social protection strategies on costs, and of TB-related costs on treatment outcomes, thus calling for further methodological developments, and outlining a clear map for future research.