Understanding treatment initiation pathways and associated costs among people with pulmonary tuberculosis in a peri-urban area of Mozambique: a cross-sectional study

Background: People with tuberculosis (TB) may seek care from healthcare providers without designated TB diagnosis and treatment services. This can lead to missed or delayed diagnosis and erroneous treatment for other diseases before being correctly diagnosed with TB. Such delays can contribute to increased out-of-pocket expenditures and lost income. We described TB treatment initiation pathways, including the type and number of pre-treatment healthcare providers visited, the time to TB treatment initiation, and the associated costs, among adults with pulmonary TB in Maputo, Mozambique.

Methods: We conducted a cross-sectional survey from December 2017 to January 2020 among adults (≥ 18 years) with pulmonary TB initiating TB treatment in health facilities with TB services in Maputo city and Maputo province, Mozambique. We used a locally adapted version of the World Health Organization’s TB Patient Cost Survey tools to collect health and socioeconomic data including symptoms, type and number of pre-treatment healthcare providers visited, and out-of-pocket costs and lost income. Logistic regression models were used to evaluate the associations of health and socioeconomic variables with the number of pre-treatment healthcare providers visited.

Results: Of 416 enrolled participants, 268 (64.4%) were male. Median age was 34.0 (IQR: 27.0-42.0) years, and 172/416 (41.4%) were breadwinners. Nearly two-thirds (61.5%, 256/416) visited two or more healthcare providers before TB treatment initiation. The mean times to first healthcare provider visits and initiation of TB treatment were 1.5 weeks (SD = 4.9) and 7.7 weeks (SD = 5.5), respectively. The mean cost of care-seeking was equivalent to 53.7% (95%CI = 38.8-68.5%) of the monthly household income and increased with additional visits to healthcare providers. Longer duration of TB symptoms prior to TB treatment initiation (aOR 6.0 [95%CI = 3.6-9.9], p < 0.001) and being in the least poor quintile of households (aOR 2.6 [95%CI = 1.3-5.5], p = 0.011) were associated with visiting two or more pre-treatment healthcare providers.

Conclusions: Most people with TB symptoms sought care within two weeks but TB treatment initiation was delayed to nearly two months after symptoms onset. This suggests that delays in TB treatment initiation may be attributable to health system factors rather than the care-seeking behaviour of people with TB in Maputo, Mozambique. Additionally, there was a substantial financial burden of care-seeking exacerbated by additional healthcare provider visits. Evidence on interventions to address delays in diagnosis and treatment, and their associated health and socioeconomic impacts in Mozambique is urgently needed.