Households of tuberculosis (TB) patients face high TB-related costs in Somalia.

Background: The out-of-pocket spending and costs incurred by households affected by tuberculosis (TB) while accessing TB services in Somalia remain unclear. This study is the first of its kind in Somalia, estimating the proportion of TB-affected households that experience catastrophic costs among individuals with TB.

Methods: A nationally representative, descriptive, cluster-sampled cross-sectional survey was conducted among individuals receiving TB care within the Somali National TB network from December 28, 2023, to February 3, 2024. It utilized retrospective data collection to gather information on participants' sociodemographic and clinical characteristics, including care models, self-reported income and expenses, and the costs (out-of-pocket expenses and indirect) associated with a single episode of TB. The survey also examined risk factors for incurring these costs and mechanisms for dissaving. TB catastrophic cost is defined as the total costs (both direct and indirect) incurred during TB illness and treatment that exceed 20% of a household's annual income.

Results: Overall, 68% (95% CI: 64%-71%) of households affected by TB in Somalia faced costs exceeding 20% of their household income. Among patients receiving first- and second-line drug treatment, the percentages were 69% (95% CI: 65%-73%) and 62% (95% CI: 52%-71%), respectively. Individuals with TB living in the Southwest states were the most likely to incur catastrophic costs associated with the disease. Self-reported monthly household income decreased by 43%, dropping from US $176 before contracting TB to US $101 during the interview. A total of 75.4% (364) of households facing TB-related catastrophic costs reported a decline in their financial situation while seeking TB services. To cope with the economic burden of TB-related catastrophic expenses, 42% (375) of individuals with TB and their households relied on one or more dis-saving strategies, such as taking out loans or selling assets.

Conclusions: This study found that almost three out of four patients in TB care and their households experience a substantive economic burden accessing TB services in Somalia, particularly during the continuation phase of their treatment, and mainly driven by the direct nonmedical costs. A sustainable and equitable social protection program is required to reduce the proportion of households facing economic burdens due to TB in Somalia.