Barriers to tuberculosis control in urban Zambia: The economic impact and burden on patients prior to diagnosis

SETTING: Chest Clinic, University Teaching Hospital, Zambia. OBJECTIVE: To study the pre-diagnosis economic impact, burden, and barriers to care- seeking for tuberculosis patients in urban Zambia. DESIGN: In-depth interviews conducted over a 9-week period with adult in-patients and out- patients registering with new pulmonary tuberculosis; data analysis using Epi Info. RESULTS: Interviews were completed by 202 patients: 64% normally worked, but 31% stopped due to their tuberculosis, with an average of 48 days off. The mean duration of illness prior to their tuberculosis registration was 63 days, with 64% of patients delaying in presenting to the Chest Clinic. Of these, 38% blamed money shortages for their delay. In seeking diagnosis, patients incurred a mean total cost equivalent to 127% of their mean monthly income ((L)UK 40 [$US 59]); direct expenditures represented 60% of this cost. In addition, patients lost, on average, 18 work days prior to diagnosis. Care-givers incurred costs equivalent to 31% of the mean monthly income ((L)UK 10 [$US 15]). CONCLUSION: The economic burden of tuberculosis on patients creates barriers to prompt diagnosis which may lead to continuing transmission of the infection. Important economic barriers include transportation expenditure, cost of 'special food', and lost income. These barriers may be reduced through interventions that reduce the number of health encounters, travel distances and duration of illness before diagnosis.