SETTING: South Africa is one of the world's 22 high tuberculosis (TB) burden countries, with the second highest number of notified rifampicin-resistant TB (R(R)-TB) and multidrug-resistant TB (MDR-TB) cases. OBJECTIVE: To estimate patient costs associated with the diagnosis and treatment of R(R)-TB/MDR-TB in South Africa. DESIGN: Patients diagnosed with R(R)-TB/MDR-TB and accessing care at government health care facilities were surveyed using a structured questionnaire. Direct and indirect costs associated with accessing R(R)-TB/MDR-TB care were estimated at different treatment durations for each patient. RESULTS: A total of 134 patients were surveyed: 84 in the intensive phase and 50 in the continuation phase of treatment, 82 in-patients and 52 out-patients. The mean monthly patient costs associated with the diagnosis and treatment of R(R)-TB/MDR-TB were higher during the intensive phase than the continuation phase (US$235 vs. US$188) and among in-patients than among out-patients (US$269 vs. US$122). Patients in the continuation phase and those accessing care as out-patients reported higher out-of-pocket costs than other patients. Most patients did not access social protection for costs associated with R(R)-TB/MDR-TB illness. CONCLUSION: Despite free health care, patients bear high costs when accessing diagnosis and treatment services for R(R)-TB/MDR-TB; appropriate social protection mechanisms should be provided to assist them in coping with these costs.