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Tuberculosis (TB) infects over 9 million people annually and is responsible for approximately 1.5 million deaths each year. Despite high treatment success rates, declines in incidence have averaged only 1.5% per year over the past decade. The newly adopted End TB Strategy sets a progressive agenda that moves beyond the medical sphere and includes a focus on upstream social determinants aimed at prevention. The strategy specifically calls for stronger poverty alleviation and social protection programs and policies. This dissertation sets out to support the need for social protection programs to combat TB, as well as attempting to answer the questions of who should be the recipients of such programs and in what form should they take.Paper one uses country-level data to show that spending on social protection is associated with decreased TB prevalence, incidence, and mortality. This work has a global purview and predicts a drop of 18 per 100,000 persons in TB prevalence rate from 1% increase in social protection spending. This is true even after adjusting for factors associated with TB rates such as level of economic development, the strength of the health system, and HIV burden.The second paper examines the relationship between household poverty and TB disease. Using household asset and characteristic data, this work creates household socioeconomic quintiles and attempts to show the relationship between this measure and individual active TB disease. The work utilized eight national TB prevalence surveys; large household surveys with a rigorous diagnostic TB algorithm. Although this approach found lower risk of TB disease for individuals in the poorest quintiles in four countries, a dose-response relationship was not observed. This paper also created an absolute wealth estimate, a US dollar-based measure of household wealth, which allowed for comparability across settings and also pooled country models. This measure of household socio-economic level did not have a clear association with individual TB risk. This work suggests novel ways of assessing the relationship between poverty and TB at the individual level that have the potential to be more efficient and to further the field of the social determinants of TB. The final paper of this dissertation focuses on a TB patient cost survey in Myanmar. This nationally representative survey includes 966 TB patients across the country and gathers information about their income and costs while seeking care. This survey is the first step in measuring the percentage of TB-affected households experiencing catastrophic costs due to the disease, defined as costs exceeding 20% of annual household income. This metric is one of the high level indicators in the End TB Strategy and will be measured by the World Health Organization and its partners in the majority of high burden countries in the coming years. The Myanmar survey found 65% of households experiencing catastrophic costs due to TB, with major cost drivers being patient’s time and additional food and/or nutritional supplements required because of the disease. Together these three papers support the need for social protection, alongside appropriate and timely medical care, in order to reach the ambitious targets set forth by the End TB Strategy.

OBJECTIVES: Tuberculosis (TB) is known as a disease of the poor. Despite TB diagnosis and care usually being offered for free, TB patients can still face substantial costs, especially in the context of multi-drug resistance (MDR). The End TB Strategy calls for zero TB-affected families incurring 'catastrophic' costs due to TB by 2025. This paper examines, by MDR status, the level and composition of costs incurred by TB-affected households during care seeking and treatment; assesses the affordability of TB care using catastrophic and impoverishment measures; and describes coping strategies used by TB-affected households to pay for TB care. METHODS: A nationally representative survey of TB patients at public health facilities across Ghana. RESULTS: We enrolled 691 patients (66 MDR). The median expenditure for non-MDR TB was US$429.6 during treatment, vs. US$659.0 for MDR patients (P-value = 0.001). Catastrophic costs affected 64.1% of patients. MDR patients were pushed significantly further over the threshold for catastrophic payments than DS patients. Payments for TB care led to a significant increase in the proportion of households in the study sample that live below the poverty line at the time of survey compared to pre-TB diagnosis. Over half of patients undertook coping strategies. CONCLUSION: TB patients in Ghana incur substantial costs, despite free diagnosis and treatment. High rates of catastrophic costs and coping strategies in both non-MDR and MDR patients show that new policies are urgently needed to ensure TB care is actually affordable for TB patients.