The Hidden Cost of TB in India: What Education and Poverty Have to Do With It

India has the highest TB burden in the world, accounting for nearly 27% of global cases. In 2022, out of the estimated 10.6 million TB cases worldwide, 2.8 million occurred in India. One of the targets for TB in the Sustainable Development Goals (SDGs) is that “zero TB patients and their households face catastrophic costs as a result of TB disease.” According to the WHO framework, catastrophic cost is defined as the total cost (direct + indirect cost) exceeding 20% of household yearly income [1]. Direct costs include medical expenses, such as diagnosis, doctor fees, and non-TB drugs, as well as non-medical expenses, including travel, accommodation, and food. Indirect costs refer to time lost due to illness, which can lead to employment disruption or job loss.

A recent study conducted across four Indian states—Assam, Maharashtra, Tamil Nadu, and West Bengal—found that 30–61% of households affected by TB face catastrophic costs [2]. The worrying aspect is that half of these households fall into financial ruin even before treatment begins, largely due to heavy borrowing. This indicates that a significant share of catastrophic costs arises during the pre-treatment phase, further contributing to delays in the initiation of actual treatment.

The Government of India, under the National TB Elimination Program (NTEP), provides free diagnosis, free medication, and INR 500 per month during the six months of treatment to all TB patients in the country [1]. Despite these provisions, a significant number of households with TB patients still incur catastrophic costs. India’s low public health spending pushes many patients toward private facilities where care is costlier. Because treatment costs are similar across income groups, poorer households bear a far heavier burden. Limited awareness and education compound the problem, driving many to self-medication or informal providers, which delays diagnosis and adds avoidable expenses before proper treatment begins.

Let us explore the roles of education and poverty as driving socio-demographic and economic factors behind these costs.

Education & Early diagnosis: A study conducted in the South 24 Parganas district of West Bengal indicated that more than 95% of TB patients were from lower socio-economic classes and had poor literacy levels.[4] Education is directly linked to income. A person with low literacy often fails to understand the importance of early testing. Instead of consulting at a public or private facility, they begin self-treatment by taking medication from a pharmacy or informal healthcare providers. This leads to delays in proper treatment and results in additional expenses on travel, unnecessary diagnostic tests, and non-TB medicines—ultimately causing financial loss, delayed diagnosis, and treatment delays.

Poverty, Unemployment & Income Loss: A significant share of TB patients in India come from poor socio-economic backgrounds, most of whom depend on daily wages. A study found that the proportion of households affected by TB facing catastrophic costs was the highest—around 60% using the Output Approach (OA)—indicating a high level of unemployment and consequent income loss [3].
In OA, the indirect cost is calculated as the difference between self-reported household income before TB and during TB treatment. While this approach captures reduced productivity in the form of income loss, it fails to account for the indirect costs of time spent by patients and caregivers not engaged in paid work (such as housewives and students).

Let us understand this with two examples,
Consider two TB patients: Patient A, a daily-wage worker, and Patient B, a salaried employee. Patient A’s household income is INR 300 per day (≈ INR 108,000 per year), while Patient B’s household income is INR 1,000 per day (≈ INR 360,000 per year).

Absolute Loss

Suppose both households incur an equal loss of INR 12,000 due to TB illness (direct + indirect cost):

• Patient A: 12,000 / 108,000 ≈ 11% of annual income — very close to WHO’s 20% catastrophic cost threshold.
• Patient B: 12,000 / 360,000 ≈ 3% of annual income — the same absolute loss, but far below WHO’s 20% threshold.

With the Output Approach (OA) Illustration

Under OA, we calculate the workdays lost (indirect cost) and multiply them by the daily wage.

Assumptions:

• Household income of a patient (daily wage) = INR 300/day ≈ 9,000/month ≈, INR 108,000/year
• Household income before treatment ≈ INR 108,000/year
• Household income at the last month of treatment: if TB causes 180 lost workdays → 180×300=INR54,000.
  This translates to nearly 50% income loss, which far exceeds the WHO’s catastrophic cost threshold of 20%.

This highlights why catastrophic costs disproportionately affect poorer and less educated households. Even with smaller absolute income losses, poorer households are more likely to cross the WHO’s 20% threshold.

Conclusion:

Despite free diagnosis, drugs, and a monthly incentive of INR 500 to all TB patients under the National TB Elimination Program in the country, a significant number of households with TB patients still experience catastrophic costs. Among them, poorer households are more likely to bear this burden, as even small absolute losses convert into a higher proportion of income, often increasing the WHO’s 20% threshold. Literacy further shapes this inequality. Patients with limited education and awareness are more likely to delay seeking appropriate care, rely on self-medication, or turn first to informal providers. These patterns increase costs, prolong illness, and worsen income loss.

Looking at the scenario, and how education and poverty are associated with catastrophic costs—possibly as coping mechanisms—three key approaches can be considered:

• Preventive measures: Strengthening patients’ knowledge, attitudes, and practices regarding treatment. This would help them understand the importance of timely treatment, reduce delays between diagnosis and initiation, and minimise income loss, thereby lowering catastrophic costs.
• Curative measures: Engaging providers or setting up camps near TB hotspots to enable early detection of TB. This would shorten delays in starting treatment and reduce associated income loss.
• Revised incentives: The current incentive of INR 500 per month, which is uniform for all TB patients regardless of socio-economic status, should be revised. Incentives should be tailored to reflect the actual economic burden faced by patients and their households.

Eventually, achieving the target of “zero catastrophic costs” will not rely only on providing free treatment, but also on coping with the structural drivers, such as poverty and education, that direct how households experience TB. Catastrophic costs will continue to be a big challenge unless these socio-economic barriers are addressed.

References:

1. https://dghs.mohfw.gov.in/national-tuberculosis-elimination-programme.php
2. https://www.who.int/publications/digital/global-tuberculosis-report-2021/uhc-tb-determinants/cost-surveys
3. Chatterjee, S., Das, P., Stallworthy, G., Bhambure, G., Munje, R., & Vassall, A. (2024). Catastrophic costs for tuberculosis patients in India: Impact of methodological choices. PLOS global public health, 4(4), e0003078.
4. Bhunia, S. K., Dey, S., Pal, A., & Giri, B. (2023). Evaluation of socio-demographic profile and basic risk factors of tuberculosis patients in South 24 Parganas district of West Bengal, India: a hospital-based study. African health sciences, 23(3), 358–365. https://doi.org/10.4314/ahs.v23i3.42