A Systematic Review and Meta-Analysis on Catastrophic Cost incurred by Tuberculosis Patients and their Households

Background: As one of the World Health Organization (WHO) End Tuberculosis (TB) Strategy is to reduce the proportion of TB affected families that face catastrophic costs to 0% by 2020. This systematic review and meta-analysis aimed to estimate the pooled proportion of TB affected households who face catastrophic cost. Method: A search of the online database through September 2020 was performed. A total of 5114 articles were found, of which 29 articles got included in quantitative synthesis. Catastrophic cost is defined if total cost related to TB exceeded 20% of annual pre-TB household income. R software was used to estimate the pooled proportion at 95% confidence intervals (CIs) using the fixed/random-effect models. Result: The proportion of patients faced catastrophic cost was 43% (95% CI 34-52, I2= 99%. 32% (95% CI 29 - 35, I2= 70%) among drug sensitive, and 80% (95% CI 74-85, I2=54%) among drug resistant, and 81% (95% CI 78-84%, I2= 0%) among HIV patients. Regarding active versus passive case finding the pooled proportion of catastrophic cost was 12% (95% CI 9-16, I2= 95%) versus 42% (95% CI 35-50, I2= 94%). The pooled proportion of direct cost to the total cost was 45% (95% CI 39-51, I2= 91%). The pooled proportion of patients facing catastrophic health expenditure (CHE) at cut of point of 10% of their yearly income was 45% (95% CI 35-56, I2= 93%) while at 40% of their capacity to pay was 63% (95% CI 40-80, I2= 96%). Conclusion: Despite the ongoing efforts, there is a significant proportion of patients facing catastrophic cost, which represent a main obstacle against TB control.


Introduction
Tuberculosis (TB) infection is one of the top 10 causes of death. It caused 1.2 million deaths in 2019. TB affects about one-quarter of the world's population [1]. According to World Health Organization (WHO) report in 2020, WHO region that reported the highest incidence of TB was Africa region (266/10 5 ) corresponding to 2.5 million cases. The South-East Asian region ranked the second (217/10 5 ) corresponding to 4.3 million cases followed by the East Mediterranean region (114/10 5 ) corresponding to 819 thousand case, and by Western Pacific region (93/10 5 ) corresponding to 1.8 million cases. On country-based ranking, number of reported new cases is the highest in India (26%), Indonesia (8.5%), China (8.4%), Philippines (6.0%), Pakistan (5.7%), Nigeria (4.4%), Bangladesh and South Africa (3.6% for each) . [2] On 26 September 2018, WHO's End TB Strategy was set and agreed by United Nation to end TB epidemic by 2030, with step wise milestones for 2020, 2025, and 2030. One of these Strategies is to reduce TB incidence rate and deaths by 90% and 95% respectively. It was also recommended to find TB missing cases by "active case finding (ACF) instead of passive case finding (PCF). ACF means systematic identification and screening of people with presumptive TB, in high-risk groups, using tests, examinations or other procedures that can be applied rapidly", while PCF entails visiting health services for diagnosis [3,4]. In addition, all TB patients or families should not suffer from catastrophic total costs (CTC) due to TB as one of the main obstacles for TB patients to complete their treatment; [5]. Catastrophic cost is defined as the total direct and indirect costs that reaches or exceed 20% of the pretreatment patient or household's annual income . [5]of note, factors that aggravate this catastrophic cost are patient age and sex, socioeconomic status, Human immuno-deficiency virus (HIV) co-infection, and being infected with multidrug-resistant TB (MDR-TB) that does not respond to at least Isoniazid and Rifampicin, the 2 most powerful anti-TB drugs [6] [7].
The nominator of catastrophic cost is the summation of direct and indirect costs. The direct cost includes either medical cost (consultation fees, diagnostic tests and treatment) or non-medical cost (transportation, accommodation, increased food needs). Indirect cost includes lost wages due to unemployment; time spent away from work and associated loss of productivity. Moreover, patients also incur large costs in the pre-treatment phase to cover consultations and laboratory tests, symptomatic treatment, antibiotics trial, and hospitalization [8]. An important segment of the financial hardship is dissaving which means reduced financial strength of a household or engage the household in damaging financial coping strategies. This will reduce the financial capacity and their coping with the financial shocks and cast them into the poverty trap . [9] Dissaving can take many forms like taking out a loan, taking children out of education, selling assets, reducing consumption to below basic needs to cope with health-related expenditure [8][9][10].
Consequently, WHO developed the TB patient cost survey to properly assess the total costs and proportion of patients facing catastrophic cost. This tool provide a standardized methodology for cross-sectional surveys in TB affected countries [11]. Many studies used this cost survey to report catastrophic cost, catastrophic health expenditure, or hardship financing incurred by TB patients [12][13][14]. Some literatures calculated catastrophic cost for drug sensitive, MDR or HIV co-infection [14][15][16]. Other studies estimated compared this cost considering adoption of different case finding strategies (ACF versus PCF) [17,18]. In response to this reported catastrophic cost, the Global TB Program endorses social protection initiatives to complement Universal health coverage (UHC) initiatives [19,20]. Examples of social protection interventions include cash transfers, food assistance, disability grants and health insurance. Those global financial supports already exist in most countries, but may not be fully implemented [7].
At the end, keeping in mind that COVID-19 pandemic may reverse the achieved progress in the TB control as many countries directed their resources toward pandemic containment. In addition, there are no published systematic reviews that report the pooled proportion of patients suffering from catastrophic cost; we aimed to perform this systematic review and meta-analysis to estimate the proportion of catastrophic cost among TB patients and their households in attempt to support the ongoing TB control programs.

Method
This systematic review and meta-analysis was conducted according to the Preferred Reporting Items of the Systematic Reviews and Meta-Analyses (PRISMA) guidelines [21].

Data source and search strategy
EMBASE, Scops, EBSCO, MEDLINE central/PubMed, ProQuest, Scielo, SAGE, Web of science, and Google scholar databases were searched for articles without timeframe, geographical or language restrictions up to November 20 th , 2020 by two authors ( ShA & NZ) then revised by (RMG& SA). Highly focused and sensitive search strategies were developed by RMG after the approval of PubMed Help Disk. The search terms include ("tuberculosis "OR "Mycobacterium tuberculosis" OR "Koch's disease" AND "catastrophic cost"). References from relevant studies were screened for supplementary articles.

Study selection and data extraction:
We aimed to include observational studies, which reported the proportion of patients suffering from catastrophic cost during the intensive (first 2 or 8 months of treatment in DS or MDR respectively) or the continuation phases of TB treatment.
The primary endpoint of interest was the proportion of TB affected patients and their households who face catastrophic cost. It was defined as the total direct and indirect costs due to TB reaches or exceed 20% of the patient or household's annual income [5] . Furthermore, CTC was assessed among patients according to their drug sensitivity as DS or MDR (with or without HIV), and strategy of case finding (ACF versus PCF).
Secondary outcomes were the proportion of the direct to the total cost of TB among DS or MDR, with or without HIV, catastrophic health expenditure CHE (defined as direct cost that reaches or exceeds 40% of patients capacity to pay or 10% of their household income [22], and the different coping strategies. Titles and abstracts were screened independently by four authors (AM, ShA, NZ, and EE), who discarded articles not pertinent to the topic. Non-observational studies, case reports, editorial, reviews, letters, and studies that estimated the direct and indirect cost of the population as a one unit not individually were excluded from qualitative analyses but screened for potential additional references. Three other authors (RMG, SA & HE) solved the discrepancies on study judgements.
Data extraction and analysis were performed by (RMG, AM, HE) and independently verified by (SA)

Data analysis:
The proportion of CTC among TB patients was pooled using the random-effects model. To ensure robustness of the model and susceptibility to outliers, pooled data was also analyzed with the fixedeffects model. Heterogeneity was assessed by the Chi-squared test on N-1 degrees of freedom, with an alpha of 0.05 considered for statistical significance and the Cochrane-I-squared (I 2 ) statistic. I2 values of 25%, 50% and 75% were considered to correspond to low, medium and high levels of heterogeneity, respectively.
Sources of heterogeneity, for identifying possible effect modifiers on the pooled analyses, were explored using: 1-Sensitivity analysis (leave one out sensitivity analysis, GOSH sensitivity analysis, remove outliers) 2-Subgroup analysis: we categorized the catastrophic cost at 20% for ACF and PCF patients according to country where studies were conducted (inside/outside) India.
3-Met-regression: The impact of country where the survey was conducted (high versus low incidence of TB) [23], quality of the study, sex, and population criteria (drug sensitivity, drug resistant with or without HIV) on the size effect of studies to explain the substantial heterogeneity.
The forest plot was used to visualize the degree of variation between studies. All data analysis was performed R software version 4.0.3 using Harrer hand-on guide [24].

Publication bias:
Publication bias was investigated by visual inspection of funnel plots, and by Egger's regression test.

Quality assessment
The Newcastle-Ottawa Scale (NOS) was used to assess the quality of studies. Studies were classified according to the NOS as: very good studies (9-10 points), good studies (7-8 points), satisfactory studies (5-6 points), and unsatisfactory studies (0-4 points). [25] . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

Publication bias:
The 29 studies reported the catastrophic cost at 20% were be assessed for the risk of bias by the funnel plot and Eggers' test [t = -1.188, P-value= 0.24], which revealed the absence of asymmetry and decline the presence of publication bias.  . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
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)
To identify the cause of this substantial heterogeneity we conducted meta-regression. Predictors were sex, country where the study conducted (had high incidence vs none) [23], drug sensitivity (DS or MDR± HIV), and quality of the study. The model was significant P<0.0127, R 2 =51.57%.
This model explained more than 50% of the reported heterogeneity. The identified predictors country (high vs low incidence) (β=-0.194, P=0.04) and type of patients regarding drug sensitivity (DS or MDR) and HIV co-infection (β=0.289, P=0.026).

Figure (3) Pooled proportion of catastrophic cost at 20%
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Coping strategy
In response to balance the enormous financial burden they encounter, the TB-affected families may adopt some coping strategies. Borrowing money, taking out loans, pledging gold and jewels, bringing their children out of schools or selling assets are options to compensate the income loss and the high out-of-pocket expenses [37,45]. All these approaches are referred to as "dissaving" which is the core of the hardship financing dilemma.

Pooled proportion of TB-HIV co-infected patients facing catastrophic cost at 20%
The pooled proportion of 796 TB patients with HIV facing catastrophic cost at 20% was 76%, 95%CI [ 65 -85%], with a heterogeneity of 88%. After conducting leave-one out sensitivity analysis, the study of Don Mudzengi et al 2017 [16], removed. The heterogeneity dropped to 0% and the pooled proportion patients facing catastrophic cost has increased to 81%, 95%CI [78 -84] as it illustrated in Figure (6) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  The proportion of patients facing catastrophic cost among 491 patients exposed active case finding ranged from 9%, 95%CI [7-15%] to 62%, 95%CI [45-77%]. After subgroup analysis based on the country where the ACF was implemented (inside/outside India). The pooled proportion was 10% 95%CI [7-14%], I 2 = 0% inside India and 48%, 95CI(25-72%) I 2 86% outside India.

Pooled proportion of TB facing catastrophic cost through passive case finding (PCF)
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(which was not certified by peer review)
The copyright holder for this preprint this version posted March 1, 2021.  The proportion of the direct cost to the total cost addressed in 6 studies, the pooled proportion of direct to total cost at catastrophic cost of 20% was not calculated as the heterogeneity was high. The proportion was variants, two studies reported similar proportions, Tomeny, 2020 [15] & Collins Timire, 2020 [47] with a proportion of 41% and 43% respectively. However, higher proportion 52% reported among Chittamany2020 [33] and Nhung, 2018 [37]. Two other extreme values reported, 33% by Fuady 2018 [41] and 65% reported by Muttamba, 2020 [30].

Pooled proportion of direct cost in MDR
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(which was not certified by peer review)
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Pooled proportion of direct cost to total cost in case of active case finding (ACF)
The pooled proportion of the direct cost to the total cost was addressed in 3 studies, the pooled proportion of direct to total cost was 25%, 95%CI [16-37%], I 2 =83%. After conducting leave one out sensitivity analysis, the Gurung, 2019 [39], was removed, the pooled proportion dropped to 29%, 95%C1 [20-41%] I 2 =55%. The pooled proportion of the direct cost to the total cost addressed in 4 studies [17,18,39,45], the pooled proportion of direct to total cost was 38%, 95%CI [32-46%], I 2 =83%. After conducting leave one out sensitivity analysis, the Shewade et al, 2018 [17], removed, the pooled proportion dropped to 37%, 95%C1 [34-40%] I 2 =0%. Figure (10) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

. Proportion of direct cost to total cost in case HIV and TB co-infection
The proportion of the direct cost to the total cost addressed in 2 studies. Don Mudzengi , 2017 [16] and his team showed that the proportion of direct cost to the total cost was 30% among HIV and TB co-infection patients, while a higher proportion reported in Chittamany, 2020 [33] with 59%. As we couldn't pool the study because of the high un-explained heterogeneity.

(which was not certified by peer review)
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Catastrophic Health Expenditure at 10% & Capacity to Pay at 40%
In this study, we have found that there are six studies that also calculated the CHE 10% and the CTP 40%, in addition to their results regarding the CTC 20%.

1 Pooled proportion of CHE at 10%:
The pooled proportion of the CHE at 10% were studied also among the studies which they calculated CTC 20%. Three studies [ 2, 27,32] were included with pooled proportion of 45%, 95%CI [35-56%], I 2 = 93%. The result after leave one out sensitivity analysis, Fuady, 2018 [40], has excluded and the heterogeneity has decreased to reach I 2 = 28%, while the pooled proportion has increased to 50%, 95%CI [47-54%]. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Discussion
Compared to the unknown data on the proportion of TB-patient affected household facing catastrophic cost in 2015, the GDGs goals set that 0% of household affected by TB have faced these costs by 2020 [51]. To the best of our knowledge, this is the first article that pooled of the proportion of TB patients or their households who suffered from catastrophic cost. In this metaanalysis 29 surveys conducted in 22 countries recruiting DS-TB, MDR-TB with or without HIV recruited through ACF, PCF. The quality score of the included studies ranged from 3-10. The proportion of patients facing catastrophic cost at a cut-off point 20% was 43%, (32%, 95%CI [29 -35]  Among drug sensitive and drug resistant TB, the proportion of direct cost to the total cost ranged from (33% to 65%) [15,30,33,37,41,47] and (26%-93%) [15,30,32,33,37,41,47] respectively. ACF incurred lower catastrophic than PCF 29%, 95%C1 [20-41%] versus 37%, 95%C1 [34-40%].
The direct cost to the total cost among TB and HIV co-infected patients ranged from 30% [16]-. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Catastrophic cost
In fact, the cost incurred by some patients may be catastrophic and minimal for others. This is based on the household annual income. In the current study, we have included many studies that addressed the catastrophic cost among the TB at different thresholds, points (30%, 25%, 20%, 10% and 5%). Despite absence of robust evidence on the sensitivity of the cut-off point at 20% to reflect the catastrophic cost regardless patients are drug sensitive or resistant. Fuady et al, [12]settled 15% and 30% as more consistent cut-of points for treatment adherence and success respectively. In the current work, the proportion of TB-household patients facing catastrophic cost was 39%, which considered very high compared to the targeted GDGs in 2020 (0)%, more efforts and activities need to be directed to reduce this cost. It is worthy to note that diagnosis and treatment are provided for free in many of the included countries under the umbrella pooled of NTP, however, the treatment related expenditure is still very high. Yadav and his group, [52] illustrated that even with free services for tuberculosis care, 21.3% of the people in their study exposed to hardship financing, advising the need to take into consideration more innovated ways to increase the supported coverage of tuberculosis treatment in the country. The study also suggests the use of hardship financing as an index to measure the effectiveness of tuberculosis control program in the country. It is crucial to decrease the burden of catastrophic cost among the TB patients as it results in poorer treatment outcome. Patients suffer from catastrophic cost had 2-4 times higher odds of treatment failure than those who do not [12]. The latter is due to reduces access to the treating health facility, and treatment completion. Turning to the coping cost, a large proportion of household's resort to different coping strategies to confront the increased out-of-pocket costs; and to compensate the consequences of income loss. Those coping strategies include selling a property or livestock, taking loans, pledging jewels, dropping their children out of school and cutting down their consumption to below basic needs [7]. Despite pooling of these studies' outcome yielded substantial heterogeneity, the current study has found that almost 51% of heterogeneity, was mainly because of two predictors, the first was that some studies estimated CTC of DS and patients with MDR with or without HIV together. This factor played a major role in the heterogeneity, as it was clear that the CTC was dramatically higher among patients with HIV. The second predictor . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted March 1, 2021. ; was the classification of country where the study was conducted [23]. Two-third of the new cases of TB reported in eight countries of the world, with India foremost the count, followed by Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa. Consequently, we divided studies into studies conducted in countries with high versus low incidence. In metaregression, the country, where the study was conducted was a second major determinant of the different size effect.
The reported high incidence of CTC in many countries raised the need for social protection interventions. The most common social protection intervention is the cash transfer or cash assistance; it has already implemented in many countries across the world either conditionally or unconditionally [53]. In such a way, it is supposed that the household can get better access to treatment and food. Other social protection interventions include disability grants, food baskets (food assistance), food or travel vouchers and social insurance [7]. Many countries implemented reimbursement programs to help TB patients to cope with the disease cost. However, these programs prioritize poorer and MDR [54].The effect of this intervention is questionable. At a cutoff point of 20%, two studies have applied and calculated a catastrophic cost before and after reimbursement. Lue et al,2020 [42] there reported a slight change on the proportion of CTC; before reimbursement, the CTC was (22%) and declined to 19% after the reimbursement. In contrary, Fuady,2019, [55] showed a higher change in the proportion of CTC after the reimbursement. The intervention program effectively decreased CTC from 44% to 13%. With regards to cash transfer, Wingfield et al, 2016 [56] reported that the proportion of TB household suffered from CTC was 30% and 42% among intervention and control respectively. These findings indicate that this social support is not enough to mitigate the impact of TB. Consequently, household of TB patients should receive sufficient financial support that covers the indirect cost (job lost), and direct cost (transportation, food, accommodation) [57].Of note, this social support should be proportionate to the income lost, this is due to the high variability of the pretreatment income. We speculate that development of newer treatment guidelines for TB of shorter duration would be beneficial. At the bottom, provision of free medication is not sufficient to prevent the catastrophic cost. TB patients should receive transport vouchers, reimbursement schemes and food assistance to reduce or compensate for such catastrophic costs. Furthermore, decentralization of patient supervision (including directly observed therapy), e.g. through community-based or workplace-based treatment [58], can reduce transport costs as well as income loss for patients [59].
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(which was not certified by peer review)
The copyright holder for this preprint this version posted March 1, 2021. ; https://doi.org/10.1101/2021.02.27.21252453 doi: medRxiv preprint As expected, the catastrophic cost among MDR was higher than DS, as DS patients receive treatment for shorter duration (6 months only), while MDR treatment extend to 24 months. Additional cost is incurred by MDR patients like the cost related to prolonged days of work absenteeism, need for daily injection, exposure to more side effects, and need for investigation [60].

Direct cost to total cost
The total direct cost to the total cost was lower than the indirect cost among drug sensitive patients, HIV co-infected patients, while it was higher among drug resistant patients. This finding is essential to be considered when reimbursement strategies are implemented. Stakeholders should know which part of patient cost should be compensated. The direct cost dropped significantly if the strategy of active case finding was adopted instead of the passive case finding (29% to 37%) respectively.

Determinant of catastrophic cost
Of note, it is essential to identify the factors that contribute to catastrophic cost. In this study, there are multiple main predictors of catastrophic cost. The main two components that affect the catastrophic cost are income loss as an impact of being diseased and food and nutritional supplements other than the patients' regular diet habit addressing the catastrophic cost through increasing the direct non-medical costs [33][34][35]. Also travel and transportation affect the direct non-medical costs increasing the suffer of TB patients [30]. Age also considered to affect the prevalence of catastrophic cost whether the young age [27] or the old age [32].

Catastrophic health expenditure
Out of the 29 studies, only six studies have been included with a clear measurement of the CHE at 10% of their income and 40% of their capacity to pay. It was clear that many studies ignored CHE, despite its importance to understand the impact of this cost on treatment outcome [42]. Two studies assessed the effect of reimbursements intervention on the CHE. Xiang et al, [61] reported a 8% reduction in CHE, however, this reduction was not statistically significant. Similarly, Zhou et al [62] reported that the effect of reimbursement on CHE was minimal, the achieved reduction . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 1, 2021. ; https://doi.org/10.1101/2021.02.27.21252453 doi: medRxiv preprint in CHE was only 12%. In order to decrease the catastrophic expenditures National health financing systems must be designed and implemented, not to allow people to access services when they are needed only, but also to protect households from financial catastrophe, by reducing out-of-pocket spending. In the long run, prepayment mechanisms should be developed, for instance, social health insurance, tax-based financing of health care, or some mix of prepayment mechanisms such as efficient reimbursement or cash intervention. [63] Strength and limitation of the study Our study has many strengths and limitations. Strengths include a comprehensive systematic approach to the existing literature, study selection, data extraction and quality assessment that have all been conducted according to current methodological standards.
Furthermore, we included all studies without design, language, or geographical restriction.
Moreover, we considered an ample list of outcomes and we compared these outcomes based on the definition, drug sensitivity and HIV infection. The limitation of this study was that different cut-off points were settled by different studies to estimate the proportion of the households facing catastrophic cost using different tools. A major challenge was that different studies estimated the catastrophic cost due to TB regardless drug sensitivity (DS, MDR), co-infection with HIV, case finding strategy (ACF, and PCF). Another point of limitation was that all studies included subjects with confirmed TB. Costs for those ill patients with undiagnosed TB may add a lot to the already estimated values. Furthermore, many of the included studies used the WHO cost survey tool, that include patients only treated in the NTP, omitting patients treated in private sectors who represent a considerable proportion of TB patients.

Conclusion
About future global policy, our study provides evidence that despite the free TB treatment policy, there is a major proportion of TB patients are still facing catastrophic cost. The proportion of patient facing catastrophic cost is variable according to the type of TB; lowest among DS, higher in MDR, and highest if there is concomitant infection with HIV. Patients exposed to ACF incurred lower cost than those exposed to PCF. The direct cost (medical &non-medical) related to TB is not the only major contributor to the catastrophic cost, indirect cost represents a major contributor that should not be ignored. To sum up, this study paves the way to effective cost mitigation in the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 1, 2021. ; https://doi.org/10.1101/2021.02.27.21252453 doi: medRxiv preprint context of the End TB Strategy. As it addressed the proportion of TB patients and their households who are suffering from catastrophic cost and its predictors. Obviously, effective management of these predictors will eventually contribute to better community, clinical, financial outcomes [64]. Now it is clear that, the global health system must do more efforts to achieve the zero catastrophic cost for TB by 2030.