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Background  While investment in the development of Tuberculosis (TB) treatment strategies is essential, it cannot be assumed that the strategies are affordable for TB patients living in countries with high economic constraints. This study aimed to determine the economic consequences of directly observed therapy for TB patients.    Methods  A cross-sectional cost-of-illness analysis was conducted between September to November 2015 among 576 randomly selected adult TB patients who were on directly observed treatment in 27 public health facilities in Addis Ababa, Ethiopia. Data were collected using interviewer-administered questionnaire adapted from the Tool to Estimate Patients’ Costs. Mean and median costs, reduction of productivity, and household expenditure of TB patients were calculated and ways of coping costs captured. Eta (η), Odds ratio and  p  values were used to measure association between variables.    Results  Of the total 576 TB patients enrolled, 43 % were smear-positive pulmonary TB (PTB), 17 % smear-negative PTB, 37 % Extra-PTB and 3 % multi-drug resistant TB cases. Direct (Out-of-Pocket) mean and median costs of TB illness to patients were $123.0 (SD = 58.8) and $125.78 ( R  = 338.12), respectively, and indirect (loss income) mean and median costs were $54.26 (SD = 43.5) and $44.61 ( R  = 215.6), respectively. Mean and median total cost of TB illness to patient were $177.3 (SD = 78.7) and $177.1 ( R  = 461.8), respectively. The total cost had significant association with patient’s household income, residence, need for additional food, and primary income ( P  <0.05). Direct costs were catastrophic for 63 % of TB patients, regardless of significant difference between gender ( P  = 0.92) and type of TB cases ( P  = 0.37). TB patients mean productivity and income reduced by 37 and 10 %, respectively, compared with pre-treatment level, while mean household expenditure increased by 33 % and working hours reduced by 78 % due to TB illness. Income quartile categories were directly correlated with catastrophic costs (η = 0.684).    Conclusion  Despite the availability of free-of-charge anti-TB drugs, TB patients were suffering from out-of-pocket payments with catastrophic consequences, which in turn were hampering the efforts to end TB. TB patients in resource-limited countries deserve integrated patient-centered care with comprehensive health insurance coverage, financial incentives, and nutrition support to reduce catastrophic costs and retain them in care. Such countries should induce home-based directly observed therapy programs to reduce costs due to attending health facilities, intensify home treatment of critically-ill patients with impaired mobility, and reduce the spread of TB due to patients traveling to seek care.    Electronic supplementary material  The online version of this article (doi:10.1186/s40249-016-0187-9) contains supplementary material, which is available to authorized users.

Tuberculosis care strategies and their economic consequences for patients: the missing link to end tuberculosis