Tuberculosis in Pakistan: A Biomedical and Economic Crisis

Tuberculosis (TB) remains one of the world’s most lethal infectious diseases, with an estimated 10.6 million new cases and 1.3 million deaths globally in 2022 (WHO, 2023). Pakistan is among the high-burden countries where TB continues to pose a dual challenge to public health and socioeconomic development. Although national TB control programs provide free diagnosis and anti-tubercular medicines, the notion of “zero-cost” treatment masks a complex web of hidden expenses that push many affected households into financial distress. For poor and near-poor families, the economic consequences of TB often rival, and sometimes exceed, the clinical burden of the disease.

Direct medical costs are only one component of this burden and are partly absorbed by the public sector. However, patients frequently incur direct non-medical costs that are substantial and unavoidable. These include repeated transportation to diagnostic centers, accommodation for patients and attendants, special nutritional requirements to cope with weight loss and weakness, and out-of-pocket payments for ancillary tests or hospital stays. In rural and peri-urban areas, long travel distances and weak referral systems further inflate these expenditures.

Even more damaging are the indirect costs associated with lost income and productivity. TB disproportionately affects adults in their prime working years, particularly daily wage laborers and informal workers who lack sick leave or social protection. Prolonged illness, frequent clinic visits, and extended treatment regimens lead to job loss, reduced working hours, and declining household earnings. In many cases, a second family member must also withdraw from work to provide care, compounding the income shock.

This financial toxicity has serious clinical consequences. Economic hardship undermines treatment adherence, contributes to treatment interruption, and increases the risk of relapse and transmission. The burden is especially severe for patients with drug-resistant TB, whose treatment is longer, more toxic, and far more expensive. Addressing TB in Pakistan therefore requires not only effective medical care, but robust financial risk protection mechanisms that shield households from catastrophic costs and break the vicious cycle between poverty and disease.

The Comprehensive Cost Burden of Tuberculosis on Pakistani Households

Even within a nominally free public health program, tuberculosis imposes a heavy and often catastrophic financial burden on patients and their families in Pakistan. Empirical evidence shows that the average total cost of a TB episode can absorb between 20 percent and more than 50 percent of annual household income, a level widely recognized as financially catastrophic (Ahmad & Siddiqui, 2021). This burden is not concentrated in one category but is distributed across medical, non-medical, and productivity-related costs that accumulate over the long course of treatment.

Direct medical costs, though partially covered by the public sector, remain significant. Patients frequently pay out of pocket for chest X-rays, GeneXpert or PCR tests, follow-up investigations, and consultations with private physicians when public facilities are overcrowded or distant (Mehmood & Akhtar, 2023). Expenditures for managing drug side effects, additional medications, and occasional hospitalization further increase financial pressure, particularly for patients with complications.

Direct non-medical costs often exceed medical expenses. Repeated travel to Directly Observed Therapy centers, lodging near tertiary hospitals, and the culturally emphasized need for improved nutrition impose a continuous drain on household resources (Baloch & Khan, 2022). For rural families, long distances and weak transport infrastructure make these costs disproportionately high.

Indirect costs from income loss represent the largest and most destabilizing component. Illness reduces the earning capacity of patients, while caregiving responsibilities divert the labor of other household members. A longitudinal study found that more than 70 percent of affected families experienced a sharp income decline, with many resorting to borrowing, asset sales, or withdrawing children from school (Noor & Malik, 2023). These coping strategies deepen poverty and entrench the long-term socioeconomic consequences of tuberculosis.

Catastrophic Health Spending and the Vicious Cycle of Poverty and Resistance

Catastrophic health expenditure is conventionally defined as health-related spending that exceeds 10–20 percent of a household’s total annual consumption, a threshold beyond which basic subsistence is threatened. In Pakistan, tuberculosis routinely crosses this boundary. Recent estimates suggest that between 47 and 67 percent of TB-affected households experience catastrophic costs, a proportion far above the global average and starkly inconsistent with the WHO End TB Strategy target of eliminating such expenditure entirely (WHO, 2023; Usman & Khan, 2025). Once this threshold is breached, households are forced into harmful coping strategies that erode both present welfare and future resilience. Families reduce food intake, compromise dietary quality, withdraw children from school, defer essential health care, take high-interest informal loans, or liquidate productive assets such as livestock and land (Shaukat & Siddiqui, 2024). These decisions generate long-lasting scarring effects, ensuring that tuberculosis does not merely afflict the poor but actively manufactures new poverty and transmits disadvantages across generations.

The economic crisis intensifies dramatically in cases of Drug-Resistant Tuberculosis. Treatment for multidrug-resistant TB extends up to twenty months, involves toxic and costly second-line drugs, and requires frequent hospitalization and monitoring. As a result, the total patient cost burden is typically three to five times higher than that for drug-susceptible disease (Hassan & Farooq, 2024). Prolonged illness magnifies income loss, while health system expenditures per case escalate sharply, underscoring the economic as well as clinical urgency of preventing resistance through rapid diagnosis, strict infection control, and adherence support.

Crucially, financial hardship itself becomes a barrier to effective TB control. Fear of transport costs delays diagnosis, daily wage dependency drives treatment interruption, and indebtedness compounds stigma and psychological distress (Khan & Ahmed, 2022; Ali & Iqbal, 2022). In this way, poverty and tuberculosis reinforce each other in a self-perpetuating cycle that undermines both individual recovery and national disease control efforts.

Integrating Financial Risk Protection into Tuberculosis Control Strategies

Effective tuberculosis control cannot be achieved through biomedical interventions alone. In high-burden settings such as Pakistan, the persistence of catastrophic patient costs demands that financial risk protection be embedded as a core pillar of TB programming. A growing body of evidence demonstrates that reducing the economic burden on households not only improves welfare but directly strengthens treatment adherence, shortens diagnostic delays, and lowers the risk of drug resistance and onward transmission.

Decentralized and community-based models of care represent one of the most cost-effective reforms. By shifting treatment supervision, drug dispensing, and follow-up from distant hospitals to community health workers and primary care facilities, programs substantially reduce transport expenditures and opportunity costs associated with repeated clinic visits. Evaluations from South Asia show that such models can cut patient travel costs by more than half while maintaining high treatment success rates (Ilyas, 2025). For daily wage earners, the ability to receive care close to home often determines whether treatment can be completed at all.

Investment in rapid molecular diagnostics constitutes a second high-impact strategy. The expansion of tools such as GeneXpert enables early and accurate detection of both drug-susceptible and drug-resistant TB, reducing the costly and prolonged diagnostic pathways that characterize conventional smear-based algorithms. Earlier diagnosis shortens the period of income loss before treatment initiation, limits unnecessary private-sector expenditures, and prevents clinical deterioration that would require hospitalization.

Most critically, comprehensive social protection packages are indispensable for shielding vulnerable households from catastrophic expenditure. Conditional cash transfers linked to treatment adherence can partially replace lost earnings and improve completion rates. Nutritional support in the form of food baskets or vouchers addresses both clinical needs and household food insecurity. Transportation vouchers remove a primary barrier to clinic attendance, particularly in rural areas. Finally, targeted schemes to cover non-medical expenses for the poorest households directly operationalize the WHO commitment to zero catastrophic costs (Global Fund, 2023).

The first priority is the institutionalization of social protection within the national TB program. Financial and nutritional support for TB-affected households should be embedded in the core program budget and planning framework, rather than confined to short-term donor-funded pilots. Predictable and nationwide coverage is essential to ensure equity across provinces and continuity of support throughout the full treatment course.

Second, the scale-up of patient-centered care models must be accelerated. Expanding the role of community health workers in directly observed therapy, follow-up treatment, and psychosocial support can substantially reduce travel costs and income losses associated with repeated facility visits. Such models also strengthen adherence and early identification of treatment complications.

Third, universal health coverage pathways should be actively leveraged. Existing health insurance schemes and social health protection programs can be adapted to cover not only essential diagnostics and hospitalization, but also ancillary medical and non-medical costs that drive catastrophic expenditure. Strategic purchasing and benefit package design can align TB services with broader UHC reforms.

Finally, robust monitoring is indispensable. Systematically tracking the proportion of TB-affected households experiencing catastrophic costs should become a key performance indicator for the national program. Without such metrics, financial hardship will remain invisible, and the End TB goal of zero catastrophic costs will remain unattainable.

Conclusion

This analysis demonstrates that tuberculosis in Pakistan is not only a biomedical emergency but a profound economic shock that systematically undermines household welfare and national disease control efforts. Despite the availability of free diagnosis and medicines, the persistence of substantial non-medical and indirect costs exposes a critical policy failure: treatment without financial protection is incomplete treatment. The evidence shows that catastrophic expenditure is not an exceptional outcome but a routine experience for nearly half of TB-affected households, with particularly devastating consequences for daily wage earners, informal workers, and families confronting drug-resistant disease.

The implications are clear. Financial hardship is not merely a social consequence of tuberculosis; it is a direct driver of delayed diagnosis, treatment interruption, relapse, and the emergence of drug resistance. If households are forced to choose between subsistence and adherence, Pakistan’s End TB targets will remain unattainable, regardless of clinical advances.

A sustainable TB strategy must therefore reposition financial risk protection as a core pillar of disease control. Decentralized care, rapid diagnostics, and comprehensive social protection packages are not ancillary welfare measures but essential public health investments. Integrating these interventions within universal health coverage reforms and rigorously monitoring catastrophic costs can transform TB control from a narrow disease program into a genuine poverty-alleviation strategy.

References: Ahmad & Siddiqui; Ali & Iqbal; Baloch & Khan; The Global Fund; Hassan & Farooq; Ilyas; Khan & Ahmed; Mehmood & Akhtar; Noor & Malik; Shaukat & Siddiqui; Usman & Khan; WHO.

Please note that the views expressed in this article are of the author and do not necessarily reflect the views or policies of any organization.

The writer is affiliated with the Department of Epidemiology and Public Health, University of Agriculture, Faisalabad Pakistan and can be reached at afshanzaman421@gmail.com 

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