Gender differences in costs and socioeconomic consequences for patients seeking TB evaluation in East and Central Uganda

Abstract

Introduction: Tuberculosis remains a major global public health problem with unequal distribution among men and women. Over 95% of new cases and 98% of deaths annually occur in the developing world where gender inequalities and poverty are common. Given the synergy between poverty and TB, and the potential associations between gender and TB as well as gender and poverty, we aimed to determine the gender differences in costs and social consequences for patients seeking tuberculosis diagnostic evaluation in Uganda, one of the 30 high TB burden countries. Methods: The study utilized data from 468 adults with TB symptoms from the patient cost and social protection survey conducted between May and December 2017 at 24 rural and peri-urban health facilities in Uganda. This data on patient costs and socioeconomic effects of TB symptoms was collected using an adapted version of the WHO’s tool to estimate patient costs. The dependent variables were costs, lost wages, and socioeconomic consequences. The independent variable was gender and covariates included time, sociodemographic and clinical factors. Costs were analyzed and regression models performed to assess for drivers of costs and lost wages by gender. Results: Of the 468 patients in the study, 48.1% were women. Women had significantly longer median duration of symptoms (5weeks vs 3weeks, p=0.003) and lower median income (Shs.50000 vs shs.200000, p<0.001) than men. Men had significantly higher median total costs (Shs.22000 vs shs.15300, p=0.003) and median lost wages (shs.5000 vs shs.0, p<0.001) than women. However, there were no differences in direct medical and non-medical costs. Women were less likely than men to report lost wages (aPR=0.76, 95% CI 0.60-0.96, p=0.023) after adjusting for covariates. A proportionately larger number of women than men experienced catastrophic costs (20.4% vs 10.2%, p<0.001) and the major drivers of catastrophic costs were travel time (aPR=1.70, 95% CI 1.29-2.24, p<0.001) and pre-illness poverty (aPR=1.55, 95% CI 1.16-2.08, p=0.003). Consequently, over half of the patients experienced stigma, loss of jobs and a significant proportion of women than men took loans (31.2% vs 21.8%, p=0.021). Conclusion: The findings of this study confirm our hypothesis that gender differences exist in costs of accessing TB diagnostic services and that patients experience serious socioeconomic consequences. Cost mitigation policies and social protection measures are warranted in order to achieve Universal Health Coverage and End TB strategy goals.