151
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Pedrazzoli D, Lalli M, Boccia D, Houben R, Kranzer K. Can tuberculosis patients in resource-constrained settings afford chest radiography? Eur Respir J 2016; 49:13993003.01877-2016. [DOI: 10.1183/13993003.01877-2016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/25/2016] [Indexed: 11/05/2022]
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152
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Torrens AW, Rasella D, Boccia D, Maciel ELN, Nery JS, Olson ZD, Barreira DCN, Sanchez MN. Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective cohort study in Brazil. Trans R Soc Trop Med Hyg 2016; 110:199-206. [PMID: 26884501 DOI: 10.1093/trstmh/trw011] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite the efforts of the National Tuberculosis Programme, TB cure rates in Brazil are sub-optimal. The End TB Strategy for post-2015 identifies conditional cash transfer interventions as powerful tools to improve TB control indicators, including TB cure rate. This study aims to inform the new policy by evaluating the role of the Bolsa Familia Programme (BFP), one of the largest conditional cash transfer programmes in the world, on TB cure rates in Brazil. METHODS We undertook a retrospective cohort study, based on an unprecedented record linkage of socioeconomic and health data, to compare cases of patients newly diagnosed with TB in 2010 receiving BFP cash benefits (n=5788) with those who did not (n=1467) during TB treatment. We used Poisson regression with robust variance to estimate the relative risks for TB cure adjusted for known confounders. RESULTS The cure rate among patients exposed to BFP during TB treatment was 82.1% (4752/5788), 5.2% higher than among those not exposed. This was confirmed after controlling for TB type, diabetes mellitus, HIV status and other relevant clinical and socioeconomic covariates (RR=1.07, 95% CI 1.04 to 1.11 for cure rates among BFP beneficiaries). This association seemed higher for patients not under directly observed treatment (RR=1.11; 95% CI 1.05 to 1.16). CONCLUSIONS Although further research is needed, this study suggests that conditional cash transfer programmes can contribute to improve TB cure rate in Brazil.
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Affiliation(s)
- Ana W Torrens
- Tropical Medicine Department, University of Brasília, Brasilía, DF, Brazil
| | | | - Delia Boccia
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Ethel L N Maciel
- Federal University of Espírito Santo, Maruipe, Vitória, DF, Brazil
| | - Joilda S Nery
- Federal University of Bahia, Institute of Collective Health, Salvador, Bahia, DF, Brazil
| | | | - Draurio C N Barreira
- National Tuberculosis Program/Ministry of Health of Brazil, Brasília, DF, Brazil
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153
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Ticona E, Huaroto L, Kirwan DE, Chumpitaz M, Munayco CV, Maguiña M, Tovar MA, Evans CA, Escombe R, Gilman RH. Impact of Infection Control Measures to Control an Outbreak of Multidrug-Resistant Tuberculosis in a Human Immunodeficiency Virus Ward, Peru. Am J Trop Med Hyg 2016; 95:1247-1256. [PMID: 27621303 PMCID: PMC5154435 DOI: 10.4269/ajtmh.15-0712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 07/31/2016] [Indexed: 11/07/2022] Open
Abstract
Multidrug-resistant tuberculosis (MDRTB) rates in a human immunodeficiency virus (HIV) care facility increased by the year 2000-56% of TB cases, eight times the national MDRTB rate. We reported the effect of tuberculosis infection control measures that were introduced in 2001 and that consisted of 1) building a respiratory isolation ward with mechanical ventilation, 2) triage segregation of patients, 3) relocation of waiting room to outdoors, 4) rapid sputum smear microscopy, and 5) culture/drug-susceptibility testing with the microscopic-observation drug-susceptibility assay. Records pertaining to patients attending the study site between 1997 and 2004 were reviewed. Six hundred and fifty five HIV/TB-coinfected patients (mean age 33 years, 79% male) who attended the service during the study period were included. After the intervention, MDRTB rates declined to 20% of TB cases by the year 2004 (P = 0.01). Extremely limited access to antiretroviral therapy and specific MDRTB therapy did not change during this period, and concurrently, national MDRTB prevalence increased, implying that the infection control measures caused the fall in MDRTB rates. The infection control measures were estimated to have cost US$91,031 while preventing 97 MDRTB cases, potentially saving US$1,430,026. Thus, this intervention significantly reduced MDRTB within an HIV care facility in this resource-constrained setting and should be cost-effective.
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Affiliation(s)
- Eduardo Ticona
- Department of Infectious Diseases, Hospital Nacional Dos de Mayo, Lima, Peru
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Luz Huaroto
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Department of Microbiology, Hospital Nacional Dos De Mayo, Lima, Peru
| | - Daniela E. Kirwan
- Department of Medical Microbiology, St George's Hospital, London, United Kingdom
- Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Milagros Chumpitaz
- Department of Infectious Diseases, Hospital Nacional Dos de Mayo, Lima, Peru
| | - César V. Munayco
- Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Mónica Maguiña
- Asociacion Benéfica Proyectos en Informatica, Salud, Medicina, y Agricultura (PRISMA), Lima, Peru
| | - Marco A. Tovar
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Carlton A. Evans
- Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
| | - Roderick Escombe
- Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
| | - Robert H. Gilman
- Asociacion Benéfica Proyectos en Informatica, Salud, Medicina, y Agricultura (PRISMA), Lima, Peru
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorios de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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154
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Wingfield T, Tovar MA, Huff D, Boccia D, Saunders MJ, Datta S, Montoya R, Ramos E, Lewis JJ, Gilman RH, Evans C. Beyond pills and tests: addressing the social determinants of tuberculosis. Clin Med (Lond) 2016; 16:s79-s91. [PMID: 27956446 PMCID: PMC6329567 DOI: 10.7861/clinmedicine.16-6-s79] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Poverty drives tuberculosis (TB) rates but the approach to TB control has been disproportionately biomedical. In 2015, the World Health Organization's End TB Strategy explicitly identified the need to address the social determinants of TB through socio-economic interventions. However, evidence concerning poverty reduction and cost mitigation strategies is limited. The research described in this article, based on the 2016 Royal College of Physicians Linacre Lecture, aimed to address this knowledge gap. The research was divided into two phases: the first phase was an analysis of a cohort study identifying TB-related costs of TB-affected households and creating a clinically relevant threshold above which those costs became catastrophic; the second was the design, implementation and evaluation of a household randomised controlled evaluation of socio-economic support to improve access to preventive therapy, increase TB cure, and mitigate the effects of catastrophic costs. The first phase showed TB remains a disease of people living in poverty - 'free' TB care was unaffordable for impoverished TB-affected households and incurring catastrophic costs was associated with as many adverse TB treatment outcomes (including death, failure of treatment, lost to follow-up and TB recurrence) as multidrug resistant (MDR) TB. The second phase showed that, in TB-affected households receiving socio-economic support, household contacts were more likely to start and adhere to TB preventive therapy, TB patients were more likely to be cured and households were less likely to incur catastrophic costs. In impoverished Peruvian shantytowns, poverty remains inextricably linked with TB and incurring catastrophic costs predicted adverse TB treatment outcome. A novel socio-economic support intervention increased TB preventive therapy uptake, improved TB treatment success and reduced catastrophic costs. The impact of the intervention on TB control is currently being evaluated by the Community Randomized Evaluation of a Socio-economic Intervention to Prevent TB (CRESIPT) study.
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Affiliation(s)
- Tom Wingfield
- Address for correspondence: Dr T Wingfield, The Ronald Ross Building, 8 West Derby Street, Liverpool L69 7BE, UK.
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155
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Wingfield T, Tovar MA, Huff D, Boccia D, Saunders MJ, Datta S, Montoya R, Ramos E, Lewis JJ, Gilman RH, Evans C. Beyond pills and tests: addressing the social determinants of tuberculosis. Clin Med (Lond) 2016; 16. [PMID: 27956446 PMCID: PMC6329567 DOI: 10.7861/clinmedicine.16-6s-s79] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Poverty drives tuberculosis (TB) rates but the approach to TB control has been disproportionately biomedical. In 2015, the World Health Organization's End TB Strategy explicitly identified the need to address the social determinants of TB through socio-economic interventions. However, evidence concerning poverty reduction and cost mitigation strategies is limited. The research described in this article, based on the 2016 Royal College of Physicians Linacre Lecture, aimed to address this knowledge gap. The research was divided into two phases: the first phase was an analysis of a cohort study identifying TB-related costs of TB-affected households and creating a clinically relevant threshold above which those costs became catastrophic; the second was the design, implementation and evaluation of a household randomised controlled evaluation of socio-economic support to improve access to preventive therapy, increase TB cure, and mitigate the effects of catastrophic costs. The first phase showed TB remains a disease of people living in poverty - 'free' TB care was unaffordable for impoverished TB-affected households and incurring catastrophic costs was associated with as many adverse TB treatment outcomes (including death, failure of treatment, lost to follow-up and TB recurrence) as multidrug resistant (MDR) TB. The second phase showed that, in TB-affected households receiving socio-economic support, household contacts were more likely to start and adhere to TB preventive therapy, TB patients were more likely to be cured and households were less likely to incur catastrophic costs. In impoverished Peruvian shantytowns, poverty remains inextricably linked with TB and incurring catastrophic costs predicted adverse TB treatment outcome. A novel socio-economic support intervention increased TB preventive therapy uptake, improved TB treatment success and reduced catastrophic costs. The impact of the intervention on TB control is currently being evaluated by the Community Randomized Evaluation of a Socio-economic Intervention to Prevent TB (CRESIPT) study.
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Affiliation(s)
- Tom Wingfield
- Address for correspondence: Dr T Wingfield, The Ronald Ross Building, 8 West Derby Street, Liverpool L69 7BE, UK.
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156
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The Financial Burden of Non-Communicable Chronic Diseases in Rural Nigeria: Wealth and Gender Heterogeneity in Health Care Utilization and Health Expenditures. PLoS One 2016; 11:e0166121. [PMID: 27832107 PMCID: PMC5104487 DOI: 10.1371/journal.pone.0166121] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022] Open
Abstract
Objectives Better insights into health care utilization and out-of-pocket expenditures for non-communicable chronic diseases (NCCD) are needed to develop accessible health care and limit the increasing financial burden of NCCDs in Sub-Saharan Africa. Methods A household survey was conducted in rural Kwara State, Nigeria, among 5,761 individuals. Data were obtained using biomedical and socio-economic questionnaires. Health care utilization, NCCD-related health expenditures and distances to health care providers were compared by sex and by wealth quintile, and a Heckman regression model was used to estimate health expenditures taking selection bias in health care utilization into account. Results The prevalence of NCCDs in our sample was 6.2%. NCCD-affected individuals from the wealthiest quintile utilized formal health care nearly twice as often as those from the lowest quintile (87.8% vs 46.2%, p = 0.002). Women reported foregone formal care more often than men (43.5% vs. 27.0%, p = 0.058). Health expenditures relative to annual consumption of the poorest quintile exceeded those of the highest quintile 2.2-fold, and the poorest quintile exhibited a higher rate of catastrophic health spending (10.8% among NCCD-affected households) than the three upper quintiles (4.2% to 6.7%). Long travel distances to the nearest provider, highest for the poorest quintile, were a significant deterrent to seeking care. Using distance to the nearest facility as instrument to account for selection into health care utilization, we estimated out-of-pocket health care expenditures for NCCDs to be significantly higher in the lowest wealth quintile compared to the three upper quintiles. Conclusions Facing potentially high health care costs and poor accessibility of health care facilities, many individuals suffering from NCCDs—particularly women and the poor—forego formal care, thereby increasing the risk of more severe illness in the future. When seeking care, the poor spend less on treatment than the rich, suggestive of lower quality care, while their expenditures represent a higher share of their annual household consumption. This calls for targeted interventions that enhance health care accessibility and provide financial protection from the consequences of NCCDs, especially for vulnerable populations.
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157
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Wingfield T, Tovar MA, Huff D, Boccia D, Montoya R, Ramos E, Lewis JJ, Gilman RH, Evans CA. The economic effects of supporting tuberculosis-affected households in Peru. Eur Respir J 2016; 48:1396-1410. [PMID: 27660507 PMCID: PMC5091496 DOI: 10.1183/13993003.00066-2016] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 06/24/2016] [Indexed: 01/24/2023]
Abstract
The End TB Strategy mandates that no tuberculosis (TB)-affected households face catastrophic costs due to TB. However, evidence is limited to evaluate socioeconomic support to achieve this change in policy and practice. The objective of the present study was to investigate the economic effects of a TB-specific socioeconomic intervention.The setting was 32 shantytown communities in Peru. The participants were from households of consecutive TB patients throughout TB treatment administered by the national TB programme. The intervention consisted of social support through household visits and community meetings, and economic support through cash transfers conditional upon TB screening in household contacts, adhering to TB treatment/chemoprophylaxis and engaging with social support. Data were collected to assess TB-affected household costs. Patient interviews were conducted at treatment initiation and then monthly for 6 months.From February 2014 to June 2015, 312 households were recruited, of which 135 were randomised to receive the intervention. Cash transfer total value averaged US$173 (3.5% of TB-affected households' average annual income) and mitigated 20% of households' TB-related costs. Households randomised to receive the intervention were less likely to incur catastrophic costs (30% (95% CI 22-38%) versus 42% (95% CI 34-51%)). The mitigation impact was higher among poorer households.The TB-specific socioeconomic intervention reduced catastrophic costs and was accessible to poorer households. Socioeconomic support and mitigating catastrophic costs are integral to the End TB strategy, and our findings inform implementation of these new policies.
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Affiliation(s)
- Tom Wingfield
- Innovation for Health and Development (IFHAD), Section of Infectious Diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
- The Monsall Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Tropical and Infectious Disease Unit, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Marco A Tovar
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
- IFHAD, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Doug Huff
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Delia Boccia
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
- Dept of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Rosario Montoya
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
| | - Eric Ramos
- IFHAD, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - James J Lewis
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
- Dept of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carlton A Evans
- Innovation for Health and Development (IFHAD), Section of Infectious Diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
- IFHAD, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
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158
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Wingfield T, Tovar MA, Huff D, Boccia D, Montoya R, Ramos E, Lewis JJ, Gilman RH, Evans CA. The economic effects of supporting tuberculosis-affected households in Peru. Eur Respir J 2016. [PMID: 27660507 DOI: 10.1183/13993003.00066–2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
The End TB Strategy mandates that no tuberculosis (TB)-affected households face catastrophic costs due to TB. However, evidence is limited to evaluate socioeconomic support to achieve this change in policy and practice. The objective of the present study was to investigate the economic effects of a TB-specific socioeconomic intervention.The setting was 32 shantytown communities in Peru. The participants were from households of consecutive TB patients throughout TB treatment administered by the national TB programme. The intervention consisted of social support through household visits and community meetings, and economic support through cash transfers conditional upon TB screening in household contacts, adhering to TB treatment/chemoprophylaxis and engaging with social support. Data were collected to assess TB-affected household costs. Patient interviews were conducted at treatment initiation and then monthly for 6 months.From February 2014 to June 2015, 312 households were recruited, of which 135 were randomised to receive the intervention. Cash transfer total value averaged US$173 (3.5% of TB-affected households' average annual income) and mitigated 20% of households' TB-related costs. Households randomised to receive the intervention were less likely to incur catastrophic costs (30% (95% CI 22-38%) versus 42% (95% CI 34-51%)). The mitigation impact was higher among poorer households.The TB-specific socioeconomic intervention reduced catastrophic costs and was accessible to poorer households. Socioeconomic support and mitigating catastrophic costs are integral to the End TB strategy, and our findings inform implementation of these new policies.
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Affiliation(s)
- Tom Wingfield
- Innovation for Health and Development (IFHAD), Section of Infectious Diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK .,Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú.,The Monsall Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Tropical and Infectious Disease Unit, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Marco A Tovar
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú.,IFHAD, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Doug Huff
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú.,Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Delia Boccia
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú.,Dept of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Rosario Montoya
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú
| | - Eric Ramos
- IFHAD, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - James J Lewis
- Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú.,Dept of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carlton A Evans
- Innovation for Health and Development (IFHAD), Section of Infectious Diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK.,Innovación Por la Salud y Desarrollo, Asociación Benéfica PRISMA, Lima, Perú.,IFHAD, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
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159
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Morishita F, Yadav RP, Eang MT, Saint S, Nishikiori N. Mitigating Financial Burden of Tuberculosis through Active Case Finding Targeting Household and Neighbourhood Contacts in Cambodia. PLoS One 2016; 11:e0162796. [PMID: 27611908 PMCID: PMC5017748 DOI: 10.1371/journal.pone.0162796] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 08/29/2016] [Indexed: 11/22/2022] Open
Abstract
Background Despite free TB services available in public health facilities, TB patients often face severe financial burden due to TB. WHO set a new global target that no TB-affected families experience catastrophic costs due to TB. To monitor the progress and strategize the optimal approach to achieve the target, there is a great need to assess baseline cost data, explore potential proxy indicators for catastrophic costs, and understand what intervention mitigates financial burden. In Cambodia, nationwide active case finding (ACF) targeting household and neighbourhood contacts was implemented alongside routine passive case finding (PCF). We analyzed household cost data from ACF and PCF to determine the financial benefit of ACF, update the baseline cost data, and explore whether any dissaving patterns can be a proxy for catastrophic costs in Cambodia. Methods In this cross-sectional comparative study, structured interviews were carried out with 108 ACF patients and 100 PCF patients. Direct and indirect costs, costs before and during treatment, costs as percentage of annual household income and dissaving patterns were compared between the two groups. Results The median total costs were lower by 17% in ACF than in PCF ($240.7 [IQR 65.5–594.6] vs $290.5 [IQR 113.6–813.4], p = 0.104). The median costs before treatment were significantly lower in ACF than in PCF ($5.1 [IQR 1.5–25.8] vs $22.4 [IQR 4.4–70.8], p<0.001). Indirect costs constituted the largest portion of total costs (72.3% in ACF and 61.5% in PCF). Total costs were equivalent to 11.3% and 18.6% of annual household income in ACF and PCF, respectively. ACF patients were less likely to dissave to afford TB-related expenses. Costs as percentage of annual household income were significantly associated with an occurrence of selling property (p = 0.02 for ACF, p = 0.005 for PCF). Conclusions TB-affected households face severe financial hardship in Cambodia. ACF has the great potential to mitigate the costs incurred particularly before treatment. Social protection schemes that can replace lost income are critically needed to compensate for the most devastating costs in TB. An occurrence of selling household property can be a useful proxy for catastrophic cost in Cambodia.
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Affiliation(s)
- Fukushi Morishita
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
- * E-mail:
| | - Rajendra-Prasad Yadav
- World Health Organization Representative Office in the Philippines, Manila, Philippines
| | - Mao Tan Eang
- National Center for Tuberculosis and Leprosy Control, Ministry of Health, Phnom Penh, Cambodia
| | - Saly Saint
- National Center for Tuberculosis and Leprosy Control, Ministry of Health, Phnom Penh, Cambodia
| | - Nobuyuki Nishikiori
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
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160
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Pedrazzoli D, Houben RM, Grede N, de Pee S, Boccia D. Food assistance to tuberculosis patients: lessons from Afghanistan. Public Health Action 2016; 6:147-53. [PMID: 27358810 DOI: 10.5588/pha.15.0076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 04/01/2016] [Indexed: 11/10/2022] Open
Abstract
Poverty, food insecurity and poor nutrition in the population are important contributors to the burden of tuberculosis (TB). For poor and food-insecure individuals, accessing and successfully completing anti-tuberculosis treatment over an extended period of time is challenging. Food and nutritional support as an incentive and enabler is employed by national TB control programmes (NTPs) worldwide as a means to encourage treatment initiation and adherence and to improve the nutritional status of patients with TB. It also offers a safety net for food-insecure households affected by TB to mitigate the financial consequences of the disease. This paper reports on the primary lessons from the review of the World Food Programme's (WFP's) Food Assistance Programme for TB patients in Afghanistan. It aims to inform the design, implementation and scale-up of TB programmes in settings where food insecurity and malnutrition are prevalent. It also documents qualitative findings that suggest that patients, their families and providers viewed food support as an important asset and an essential element of the national TB control strategy. While the impact on treatment success or case detection could not be quantified, it is likely that the WFP intervention had a positive impact on the patients and their households, therefore contributing to the success of the DOTS-based NTP.
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Affiliation(s)
- D Pedrazzoli
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - R M Houben
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - N Grede
- World Food Programme (WFP) Country Office, San Salvador, El Salvador
| | - S de Pee
- Nutrition Division, WFP, Rome, Italy
| | - D Boccia
- Faculty of Epidemiology and Population Health, LSHTM, London, UK
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161
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Boccia D, Pedrazzoli D, Wingfield T, Jaramillo E, Lönnroth K, Lewis J, Hargreaves J, Evans CA. Towards cash transfer interventions for tuberculosis prevention, care and control: key operational challenges and research priorities. BMC Infect Dis 2016; 16:307. [PMID: 27329161 PMCID: PMC4915091 DOI: 10.1186/s12879-016-1529-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/30/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cash transfer interventions are forms of social protection based on the provision of cash to vulnerable households with the aim of reduce risk, vulnerability, chronic poverty and improve human capital. Such interventions are already an integral part of the response to HIV/AIDS in some settings and have recently been identified as a core element of World Health Organization's End TB Strategy. However, limited impact evaluations and operational evidence are currently available to inform this policy transition. DISCUSSION This paper aims to assist national tuberculosis (TB) programs with this new policy direction by providing them with an overview of concepts and definitions used in the social protection sector and by reviewing some of the most critical operational aspects associated with the implementation of cash transfer interventions. These include: 1) the various implementation models that can be used depending on the context and the public health goal of the intervention; 2) the main challenges associated with the use of conditionalities and how they influence the impact of cash transfer interventions on health-related outcomes; 3) the implication of targeting diseases-affected households and or individuals versus the general population; and 4) the financial sustainability of including health-related objectives within existing cash transfer programmes. We aimed to appraise these issues in the light of TB epidemiology, care and prevention. For our appraisal we draw extensively from the literature on cash transfers and build upon the lessons learnt so far from other health outcomes and mainly HIV/AIDS. CONCLUSIONS The implementation of cash transfer interventions in the context of TB is still hampered by important knowledge gaps. Initial directions can be certainly derived from the literature on cash transfers schemes and other public health challenges such as HIV/AIDS. However, the development of a solid research agenda to address persisting unknowns on the impact of cash transfers on TB epidemiology and control is vital to inform and support the adoption of the post-2015 End TB strategy.
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Affiliation(s)
- Delia Boccia
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, Keppel Street, WC1E 7HT, London, UK.
| | - Debora Pedrazzoli
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, Keppel Street, WC1E 7HT, London, UK
| | - Tom Wingfield
- Infectious Disease & Immunity and Wellcome Trust Centre for Global Health Research, Imperial College, London, UK
- The Monsall Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK
| | - Ernesto Jaramillo
- World Health Organization, Global Tuberculosis Programme, Geneva, Switzerland
| | - Knut Lönnroth
- World Health Organization, Global Tuberculosis Programme, Geneva, Switzerland
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - James Lewis
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, Keppel Street, WC1E 7HT, London, UK
| | - James Hargreaves
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
| | - Carlton A Evans
- Infectious Disease & Immunity and Wellcome Trust Centre for Global Health Research, Imperial College, London, UK
- Innovation For Health And Development (IFHAD), Universidad Peruana Cayetano Heredia, Lima, Peru
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162
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Gianella C, Ugarte-Gil C, Caro G, Aylas R, Castro C, Lema C. TB in Vulnerable Populations: The Case of an Indigenous Community in the Peruvian Amazon. Health Hum Rights 2016; 18:55-68. [PMID: 27780999 PMCID: PMC5070680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
This article analyzes the factors associated with vulnerability of the Ashaninka, the most populous indigenous Peruvian Amazonian people, to tuberculosis (TB). By applying a human rights-based analytical framework that assesses public policy against human rights standards and principles, and by offering a step-by-step framework for a full assessment of compliance, it provides evidence of the relationship between the incidence of TB among the Ashaninka and Peru's poor level of compliance with its human rights obligations. The article argues that one of the main reasons for the historical vulnerability of the Ashaninka to diseases such as TB is a lack of political will on the part of the national government to increase public health spending, ensure that resources reach the most vulnerable population, and adopt and invest in a culturally appropriate health system.
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Affiliation(s)
- Camila Gianella
- Researcher at Chr. Michelsen Institute in Bergen, Norway, and post-doc researcher at the Department of Comparative Politics, University of Bergen, Norway
| | - César Ugarte-Gil
- Consultant at Salud Sin Limites Peru, and Research Associate at Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru; and PhD student at Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Godofredo Caro
- TB consultant medical doctor at Mantaro Health Network, Junin Health Directorate, Junín, Perú
| | - Rula Aylas
- Member of the technical team at Indigenous Health Directorade at the Ministry of Health, Lima, Perú
| | - César Castro
- Lecturer at School of Nursing Universidad Peruana Los Andes, Huancayo, Perú
| | - Claudia Lema
- Executive Director at Salud Sin Limites Peru, Lima, Peru
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163
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Furin J, Cox H. Outbreak of multidrug-resistant tuberculosis on Daru Island. THE LANCET RESPIRATORY MEDICINE 2016; 4:347-9. [DOI: 10.1016/s2213-2600(16)00101-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/08/2016] [Indexed: 11/24/2022]
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164
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van Hoorn R, Jaramillo E, Collins D, Gebhard A, van den Hof S. The Effects of Psycho-Emotional and Socio-Economic Support for Tuberculosis Patients on Treatment Adherence and Treatment Outcomes - A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0154095. [PMID: 27123848 PMCID: PMC4849661 DOI: 10.1371/journal.pone.0154095] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 04/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is uncertainty about the contribution that social support interventions (SSI) can have in mitigating the personal, social and economic costs of tuberculosis (TB) treatment on patients, and improving treatment outcomes. OBJECTIVE To identify psycho-emotional (PE) and socio-economic (SE) interventions provided to TB patients and to assess the effects of these interventions on treatment adherence and treatment outcomes. SEARCH STRATEGY We searched PubMed and Embase from 1 January 1990-15 March 2015 and abstracts of the Union World Conference on Lung Health from 2010-2014 for studies reporting TB treatment adherence and treatment outcomes following SSI. SELECTION CRITERIA Studies measuring the effects of PE or SE interventions on TB treatment adherence, treatment outcomes, and/or financial burden. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed titles and abstracts for inclusion of articles. One reviewer reviewed full text articles and the reference list of selected studies. A second reviewer double checked all extracted information against the articles. MAIN RESULTS Twenty-five studies were included in the qualitative analysis; of which eighteen were included in the meta-analysis. Effects were pooled from 11 Randomized Controlled Trials (RCTs), including 9,655 participants with active TB. Meta-analysis showed that PE support (RR 1.37; CI 1.08-1.73), SE support (RR 1.08; CI 1.03-1.13) and combined PE and SE support (RR 1.17; CI 1.12-1.22) were associated with a significant improvement of successful treatment outcomes. Also PE support, SE support and a combination of these types of support were associated with reductions in unsuccessful treatment outcomes (PE: RR 0.46; CI 0.22-0.96, SE: RR 0.78; CI 0.69-0.88 and Combined PE and SE: RR 0.42; CI 0.23-0.75). Evidence on the effect of PE and SE interventions on treatment adherence were not meta-analysed because the interventions were too heterogeneous to pool. No evidence was found to show whether SE reduced the financial burden for TB patients. DISCUSSION AND CONCLUSIONS Our review and meta-analysis concluded that PE and SE interventions are associated with beneficial effects on TB treatment outcomes. However, the quality of evidence is very low and future well-designed evaluation studies are needed.
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Affiliation(s)
- Rosa van Hoorn
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | | | - David Collins
- Management Sciences for Health, Boston, United States of America
| | - Agnes Gebhard
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Susan van den Hof
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Department of Global Health, Academic Medical Center and Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands
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165
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Fighting poverty to prevent tuberculosis. THE LANCET. INFECTIOUS DISEASES 2016; 16:395-6. [PMID: 26725447 DOI: 10.1016/s1473-3099(15)00434-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/04/2015] [Indexed: 12/15/2022]
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166
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Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med 2016; 14:41. [PMID: 27006009 PMCID: PMC4804546 DOI: 10.1186/s12916-016-0584-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is a major public health problem requiring complex treatment, the success of which depends on biological, social, and institutional factors. São Paulo State (SPS), in Brazil, has a high TB burden. Because of high socioeconomic heterogeneity and chaotic urbanisation, homelessness might play an important role in the TB burden in SPS. Our aim was to determine the association between homelessness and outcome of treatment of pulmonary TB (PTB) in SPS. METHODS A historical cohort from the routine SPS TB database for 2009-2013 was analysed. The study population was newly diagnosed adult patients with PTB. Homelessness was ascertained at notification or when treatment started. Our outcome was unsuccessful outcome of treatment. We used logistic regression to adjust for potential confounders and multiple imputation for missing data. RESULTS We analysed 61,817 patients; 1726 (2.8 %, 95%CI 2.7-2.9 %) were homeless. Homeless patients were concentrated in bigger cities, were more frequently middle-aged males, had black/brown skin colour, and had received less education (P < 0.001, for all). Alcohol and drug use was three times more frequent in homeless patients (43.2 % vs 14.4 %, 30.2 % vs. 9.4 %, P < 0.001, respectively). HIV testing was less common among the homeless, of whom 17.3 % were HIV positive compared with 8.5 % among the not homeless population (P < 0.001). Microbiologic confirmation was more frequent among the homeless (91.6 % vs. 84.8 %, P < 0.001). Unsuccessful outcome of treatment was 57.3 % among the homeless and 17.5 % among the not homeless (OR = 6.32, 95%CI 5.73-6.97, P < 0.001), mainly due to loss to follow-up (39 %) and death (10.5 %). After full-adjustment for potential confounders, homelessness remained strongly associated with lower treatment success (aOR = 4.96, 95 % CI 4.27-5.76, P < 0.001). HIV status interacted with homelessness: among HIV-infected patients, the aOR was 2.45 (95%CI 1.90-3.16, Pinteraction < 0.001). The population attributable fraction for the joint effect of homelessness, alcohol and drug use was almost 20 %. CONCLUSIONS Confirming our hypothesis, homelessness led to a marked reduction in the successful treatment of newly diagnosed pulmonary tuberculosis. Homelessness and associated conditions were important contributors to lack of treatment success in pulmonary tuberculosis in São Paulo. A multifaceted intervention must be implemented to target this vulnerable population.
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Affiliation(s)
- Otavio T Ranzani
- Pulmonary Division, Heart Institute (InCor), Medical School, University of São Paulo, Av. Dr. Arnaldo, 455, 2° andar, sala 2144, Post-code 01246903, São Paulo, Brazil. .,London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, Room G9a, Post-code WC1E 7HT, London, UK.
| | - Carlos R R Carvalho
- Pulmonary Division, Heart Institute (InCor), Medical School, University of São Paulo, Av. Dr. Arnaldo, 455, 2° andar, sala 2144, Post-code 01246903, São Paulo, Brazil
| | - Eliseu A Waldman
- Department of Epidemiology, Faculty of Public Health, University of Sao Paulo, Av. Dr. Arnaldo, 715, Post-code 01246904, São Paulo, Brazil
| | - Laura C Rodrigues
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, Room G9a, Post-code WC1E 7HT, London, UK
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167
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Gomes MGM, Barreto ML, Glaziou P, Medley GF, Rodrigues LC, Wallinga J, Squire SB. End TB strategy: the need to reduce risk inequalities. BMC Infect Dis 2016; 16:132. [PMID: 27001766 PMCID: PMC4802713 DOI: 10.1186/s12879-016-1464-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/10/2016] [Indexed: 12/19/2022] Open
Abstract
Background Diseases occur in populations whose individuals differ in essential characteristics, such as exposure to the causative agent, susceptibility given exposure, and infectiousness upon infection in the case of infectious diseases. Discussion Concepts developed in demography more than 30 years ago assert that variability between individuals affects substantially the estimation of overall population risk from disease incidence data. Methods that ignore individual heterogeneity tend to underestimate overall risk and lead to overoptimistic expectations for control. Concerned that this phenomenon is frequently overlooked in epidemiology, here we feature its significance for interpreting global data on human tuberculosis and predicting the impact of control measures. Summary We show that population-wide interventions have the greatest impact in populations where all individuals face an equal risk. Lowering variability in risk has great potential to increase the impact of interventions. Reducing inequality, therefore, empowers health interventions, which in turn improves health, further reducing inequality, in a virtuous circle. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1464-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Gabriela M Gomes
- Liverpool School of Tropical Medicine, Liverpool, UK. .,CIBIO-InBIO, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Vila do Conde, Portugal. .,Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil.
| | - Maurício L Barreto
- Centro de Pesquisas Gonçalo Moniz, FIOCRUZ, Salvador, Brazil.,Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Jacco Wallinga
- Department of Infectious Diseases Epidemiology, National Institute of Public Health and the Environment, PO Box 1, 3720 BA, Bilthoven, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Sweeney S, Vassall A, Foster N, Simms V, Ilboudo P, Kimaro G, Mudzengi D, Guinness L. Methodological Issues to Consider When Collecting Data to Estimate Poverty Impact in Economic Evaluations in Low-income and Middle-income Countries. HEALTH ECONOMICS 2016; 25 Suppl 1:42-52. [PMID: 26774106 PMCID: PMC5066802 DOI: 10.1002/hec.3304] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 10/14/2015] [Accepted: 11/11/2015] [Indexed: 05/06/2023]
Abstract
Out-of-pocket spending is increasingly recognized as an important barrier to accessing health care, particularly in low-income and middle-income countries (LMICs) where a large portion of health expenditure comes from out-of-pocket payments. Emerging universal healthcare policies prioritize reduction of poverty impact such as catastrophic and impoverishing healthcare expenditure. Poverty impact is therefore increasingly evaluated alongside and within economic evaluations to estimate the impact of specific health interventions on poverty. However, data collection for these metrics can be challenging in intervention-based contexts in LMICs because of study design and practical limitations. Using a set of case studies, this letter identifies methodological challenges in collecting patient cost data in LMIC contexts. These components are presented in a framework to encourage researchers to consider the implications of differing approaches in data collection and to report their approach in a standardized and transparent way.
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Affiliation(s)
- Sedona Sweeney
- London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Vassall
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Victoria Simms
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Godfather Kimaro
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | - Lorna Guinness
- London School of Hygiene & Tropical Medicine, London, UK
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169
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Ramma L, Cox H, Wilkinson L, Foster N, Cunnama L, Vassall A, Sinanovic E. Patients' costs associated with seeking and accessing treatment for drug-resistant tuberculosis in South Africa. Int J Tuberc Lung Dis 2015; 19:1513-9. [PMID: 26614194 PMCID: PMC6548556 DOI: 10.5588/ijtld.15.0341] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- L Ramma
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - H Cox
- Division of Medical Microbiology, and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - L Wilkinson
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - N Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - L Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - A Vassall
- London School of Hygiene & Tropical Medicine, London, UK
| | - E Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Madan J, Lönnroth K, Laokri S, Squire SB. What can dissaving tell us about catastrophic costs? Linear and logistic regression analysis of the relationship between patient costs and financial coping strategies adopted by tuberculosis patients in Bangladesh, Tanzania and Bangalore, India. BMC Health Serv Res 2015; 15:476. [PMID: 26493155 PMCID: PMC4618866 DOI: 10.1186/s12913-015-1138-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022] Open
Abstract
Background Tuberculosis (TB) is a major global public health problem which affects poorest individuals the worst. A high proportion of patients incur ‘catastrophic costs’ which have been shown to result in severe financial hardship and adverse health outcomes. Data on catastrophic cost incidence is not routinely collected, and current definitions of this indicator involve several practical and conceptual barriers to doing so. We analysed data from TB programmes in India (Bangalore), Bangladesh and Tanzania to determine whether dissaving (the sale of assets or uptake of loans) is a useful indicator of financial hardship. Methods Data were obtained from prior studies of TB patient costs in Bangladesh (N = 96), Tanzania (N = 94) and Bangalore (N = 891). These data were analysed using logistic and linear multivariate regression to determine the association between costs (absolute and relative to income) and both the presence of dissaving and the amounts dissaved. Results After adjusting for covariates such as age, sex and rural/urban location, we found a significant positive association between the occurrence of dissaving and total costs incurred in Tanzania and Bangalore. We further found that, for patients in Bangalore an increase in dissaving of $10 USD was associated with an increase in the cost-income ratio of 0.10 (p < 0.001). For low-income patients in Bangladesh, an increase in dissaving of $10 USD was associated with an increase in total costs of $7 USD (p <0.001). Conclusions Dissaving is potentially a convenient proxy for catastrophic costs that does not require usage of complex patient cost questionnaires. It also offers an informative indicator of financial hardship in its own right, and could therefore play an important role as an indicator to monitor and evaluate the impact of financial protection and service delivery interventions in reducing hardship and facilitating universal health coverage. Further research is required to understand the patterns and types of dissaving that have the strongest relationship with financial hardship and clinical outcomes in order to move toward evidence-based policy making.
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Affiliation(s)
- Jason Madan
- Division of Health Sciences, Warwick Medical School, Coventry, UK. .,Collaboration for Applied Health Research and Delivery, Liverpool School of Tropical Medicine and Warwick Medical School, Liverpool and Coventry, UK.
| | - Knut Lönnroth
- Global TB Programme, World Health Organisation, Geneva, Switzerland. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Samia Laokri
- Department of Global Health Systems and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA. .,Hoover Fellow of the Belgian American Educational Fund (BAEF), Brussels, Belgium.
| | - Stephen Bertel Squire
- Collaboration for Applied Health Research and Delivery, Liverpool School of Tropical Medicine and Warwick Medical School, Liverpool and Coventry, UK. .,Hoover Fellow of the Belgian American Educational Fund (BAEF), Brussels, Belgium. .,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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171
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Westerlund EE, Tovar MA, Lönnermark E, Montoya R, Evans CA. Tuberculosis-related knowledge is associated with patient outcomes in shantytown residents; results from a cohort study, Peru. J Infect 2015; 71:347-57. [PMID: 26033695 PMCID: PMC7617110 DOI: 10.1016/j.jinf.2015.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Tuberculosis is frequent among poor and marginalized people whose limited tuberculosis-related knowledge may impair healthcare access. We characterised tuberculosis-related knowledge and associations with delayed treatment and treatment outcome. METHODS Tuberculosis patients (n = 943), people being tested for suspected tuberculosis (n = 2020), and randomly selected healthy controls (n = 476) in 16 periurban shantytowns were interviewed characterizing: socio-demographic factors; tuberculosis risk-factors; and patients' treatment delay. Principle component analysis was used to generate a tuberculosis-related knowledge score. Patients were followed-up for median 7.7 years. Factors associated with tuberculosis treatment delay, treatment outcome and tuberculosis recurrence were assessed using linear, logistic and Cox regression. RESULTS Tuberculosis-related knowledge was poor, especially in older people who had not completed schooling and had never been diagnosed with tuberculosis. Tuberculosis treatment delay was median 60 days and was more delayed for patients who were poorer, older, had more severe tuberculosis and in only unadjusted analysis with incomplete schooling and low tuberculosis-related knowledge (all p ≤ 0.03). Lower than median tuberculosis-related knowledge was associated with tuberculosis recurrence (unadjusted hazard ratio = 2.1, p = 0.008), and this association was independent of co-morbidities, disease severity and demographic factors (multiple regression adjusted hazard ratio = 2.6, p = 0.008). CONCLUSIONS Low tuberculosis-related knowledge independently predicted tuberculosis recurrence. Thus health education may improve tuberculosis prognosis.
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Affiliation(s)
- Emma E Westerlund
- IFHAD: Innovation For Health And Development, Laboratory of Research and Development #218, Universidad Peruana Cayetano Heredia, San Martin de Porres, Lima, Peru; Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Marco A Tovar
- IFHAD: Innovation For Health And Development, Laboratory of Research and Development #218, Universidad Peruana Cayetano Heredia, San Martin de Porres, Lima, Peru; Innovacion Por la Salud Y el Desarollo (IPSYD), Asociación Benefica Prisma, Lima, Peru
| | - Elisabet Lönnermark
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Rosario Montoya
- Innovacion Por la Salud Y el Desarollo (IPSYD), Asociación Benefica Prisma, Lima, Peru
| | - Carlton A Evans
- IFHAD: Innovation For Health And Development, Laboratory of Research and Development #218, Universidad Peruana Cayetano Heredia, San Martin de Porres, Lima, Peru; Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK.
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172
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Wingfield T, Boccia D, Tovar MA, Huff D, Montoya R, Lewis JJ, Gilman RH, Evans CA. Designing and implementing a socioeconomic intervention to enhance TB control: operational evidence from the CRESIPT project in Peru. BMC Public Health 2015; 15:810. [PMID: 26293238 PMCID: PMC4546087 DOI: 10.1186/s12889-015-2128-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 08/07/2015] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Cash transfers are key interventions in the World Health Organisation's post-2015 global TB policy. However, evidence guiding TB-specific cash transfer implementation is limited. We designed, implemented and refined a novel TB-specific socioeconomic intervention that included cash transfers, which aimed to support TB prevention and cure in resource-constrained shantytowns in Lima, Peru for: the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB (CRESIPT) project. METHODS Newly-diagnosed TB patients from study-site healthposts were eligible to receive the intervention consisting of economic and social support. Economic support was provided to patient households through cash transfers on meeting the following conditions: screening for TB in household contacts and MDR TB in patients; adhering to TB treatment and chemoprophylaxis; and engaging with CRESIPT social support (household visits and community meetings). To evaluate project acceptability, quantitative and qualitative feedback was collected using a mixed-methods approach during formative activities. Formative activities included consultations, focus group discussions and questionnaires conducted with the project team, project participants, civil society and stakeholders. RESULTS Over 7 months, 135 randomly-selected patients and their 647 household contacts were recruited from 32 impoverished shantytown communities. Of 1299 potential cash transfers, 964 (74 %) were achieved, 259 (19 %) were not achieved, and 76 (7 %) were yet to be achieved. Of those achieved, 885/964 (92 %) were achieved optimally and 79/964 (8 %) sub-optimally. Key project successes were identified during 135 formative activities and included: strong multi-sectorial collaboration; generation of new evidence for TB-specific cash transfer; and the project being perceived as patient-centred and empowering. Challenges included: participant confidence being eroded through cash transfer delays, hidden account-charges and stigma; access to the initial bank-provider being limited; and conditions requiring participation of all TB-affected household members (e.g. community meetings) being hard to achieve. Refinements were made to improve project acceptability and future impact: the initial bank-provider was changed; conditional and unconditional cash transfers were combined; cash transfer sums were increased to a locally-appropriate, evidence-based amount; and cash transfer size varied according to patient household size to maximally reduce mitigation of TB-related costs and be more responsive to household needs. CONCLUSIONS A novel TB-specific socioeconomic intervention including conditional cash transfers has been designed, implemented, refined and is ready for impact assessment, including by the CRESIPT project. The lessons learnt during this research will inform policy-makers and decision-makers for future implementation of related interventions.
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Affiliation(s)
- Tom Wingfield
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Innovation For Health And Development (IFHAD), Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK.
- The Monsall Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK.
| | - Delia Boccia
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Marco A Tovar
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Innovation For Health And Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Doug Huff
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
| | - Rosario Montoya
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
| | - James J Lewis
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Carlton A Evans
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Innovation For Health And Development (IFHAD), Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK.
- Innovation For Health And Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru.
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Zelner JL, Murray MB, Becerra MC, Galea J, Lecca L, Calderon R, Yataco R, Contreras C, Zhang Z, Manjourides J, Grenfell BT, Cohen T. Identifying Hotspots of Multidrug-Resistant Tuberculosis Transmission Using Spatial and Molecular Genetic Data. J Infect Dis 2015; 213:287-94. [PMID: 26175455 DOI: 10.1093/infdis/jiv387] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/08/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND We aimed to identify and determine the etiology of "hotspots" of concentrated multidrug-resistant tuberculosis (MDR-tuberculosis) risk in Lima, Peru. METHODS From 2009 to 2012, we conducted a prospective cohort study among households of tuberculosis cases from 106 health center (HC) areas in Lima, Peru. All notified tuberculosis cases and their household contacts were followed for 1 year. Symptomatic individuals were screened by microscopy and culture; positive cultures were tested for drug susceptibility (DST) and genotyped by 24-loci mycobacterial interspersed repetitive units-variable-number tandem repeats (MIRU-VNTR). RESULTS 3286 individuals with culture-confirmed disease, DST, and 24-loci MIRU-VNTR were included in our analysis. Our analysis reveals: (1) heterogeneity in annual per-capita incidence of tuberculosis and MDR-tuberculosis by HC, with a rate of MDR-tuberculosis 89 times greater (95% confidence interval [CI], 54,185) in the most-affected versus the least-affected HC; (2) high risk for MDR-tuberculosis in a region spanning several HCs (odds ratio = 3.19, 95% CI, 2.33, 4.36); and (3) spatial aggregation of MDR-tuberculosis genotypes, suggesting localized transmission. CONCLUSIONS These findings reveal that localized transmission is an important driver of the epidemic of MDR-tuberculosis in Lima. Efforts to interrupt transmission may be most effective if targeted to this area of the city.
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Affiliation(s)
- Jonathan L Zelner
- Robert Wood Johnson Foundation Health and Society Scholars Program, Interdisciplinary Center for Innovative Theory and Empirics (INCITE) & Mailman School of Public Health, Columbia University, New York, New York
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Department of Epidemiology, Harvard School of Public Health
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Zibiao Zhang
- Division of Global Health Equity, Brigham and Women's Hospital
| | - Justin Manjourides
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Bryan T Grenfell
- Department of Ecology and Evolutionary Biology, Princeton University, New Jersey Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
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174
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Effect of a comprehensive programme to provide universal access to care for sputum-smear-positive multidrug-resistant tuberculosis in China: a before-and-after study. LANCET GLOBAL HEALTH 2015; 3:e217-28. [DOI: 10.1016/s2214-109x(15)70021-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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175
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Williamson J, Ramirez R, Wingfield T. Health, healthcare access, and use of traditional versus modern medicine in remote Peruvian Amazon communities: a descriptive study of knowledge, attitudes, and practices. Am J Trop Med Hyg 2015; 92:857-864. [PMID: 25688165 PMCID: PMC4385786 DOI: 10.4269/ajtmh.14-0536] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 11/09/2014] [Indexed: 11/15/2022] Open
Abstract
There is an urgent need for healthcare research, funding, and infrastructure in the Peruvian Amazon. We performed a descriptive study of health, health knowledge and practice, and healthcare access of 13 remote communities of the Manatí and Amazon Rivers in northeastern Peru. Eighty-five adults attending a medical boat service were interviewed to collect data on socioeconomic position, health, diagnosed illnesses, pain, healthcare access, and traditional versus modern medicine use. In this setting, poverty and gender inequality were prevalent, and healthcare access was limited by long distances to the health post and long waiting times. There was a high burden of reported pain (mainly head and musculoskeletal) and chronic non-communicable diseases, such as hypertension (19%). Nearly all participants felt that they did not completely understand their diagnosed illnesses and wanted to know more. Participants preferred modern over traditional medicine, predominantly because of mistrust or lack of belief in traditional medicine. Our findings provide novel evidence concerning transitional health beliefs, hidden pain, and chronic non-communicable disease prevalence in marginalized communities of the Peruvian Amazon. Healthcare provision was limited by a breach between health education, knowledge, and access. Additional participatory research with similar rural populations is required to inform regional healthcare policy and decision-making.
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Affiliation(s)
| | | | - Tom Wingfield
- *Address correspondence to Tom Wingfield, Infectious Diseases and Immunity, Imperial College London and Wellcome Trust Imperial College Centre for Global Health Research, Hammersmith Campus, Du Cane Road, W12 0NN London, United Kingdom. E-mail:
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176
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Foster N, Vassall A, Cleary S, Cunnama L, Churchyard G, Sinanovic E. The economic burden of TB diagnosis and treatment in South Africa. Soc Sci Med 2015; 130:42-50. [PMID: 25681713 DOI: 10.1016/j.socscimed.2015.01.046] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Social protection against the cost of illness is a central policy objective of Universal Health Coverage and the post-2015 Global strategy for Tuberculosis (TB). Understanding the economic burden associated with TB illness and care is key to identifying appropriate interventions towards achieving this target. The aims of this study were to identify points in patient pathways from start of TB symptoms to treatment completion where interventions could be targeted to reduce the economic impact on patients and households, and to identify those most vulnerable to these costs. Two cohorts of patients accessing TB services from ten clinics in four provinces in South Africa were surveyed between July 2012 and June 2013. One cohort of 351 people with suspected TB were interviewed at the point of receiving a TB diagnostic and followed up six months later. Another cohort of 168 patients on TB treatment, at the same ten facilities, was interviewed at two-months and five-months on treatment. Patients were asked about their health-seeking behaviour, associated costs, income loss, and coping strategies used. Patients incurred the greatest share of TB episode costs (41%) prior to starting treatment, with the largest portion of these costs being due to income loss. Poorer patients incurred higher direct costs during treatment than those who were less poor but only 5% of those interviewed were accessing cash-transfers during treatment. Indirect costs accounted for 52% of total episode cost. Despite free TB diagnosis and care in South Africa, patients incur substantial direct and indirect costs particularly prior to starting treatment. The poorest group of patients were incurring higher costs, with fewer resources to pay for it. Both the direct and indirect cost of illness should be taken into account when setting levels of financial protection and social support, to prevent TB illness from pushing the poor further into poverty.
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Affiliation(s)
- Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa.
| | - Anna Vassall
- Social and Mathematical Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa
| | - Gavin Churchyard
- Aurum Institute, Queens Road, Parktown, Johannesburg, South Africa; Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa
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177
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Abstract
OBJECTIVE To review the latest information about tuberculosis (TB) drug resistance and programmatic management of drug-resistant TB in the Western Pacific Region of the World Health Organization (WHO). METHODS We analysed routine data reported by countries to WHO from 2007 to 2013, focusing on data from the following: surveillance and surveys of drug resistance, management of drug-resistant TB and financing related to multidrug-resistant TB (MDR-TB) management. RESULTS In the Western Pacific Region, 4% (95% confidence interval [CI]: 3-6) of new and 22% (95% CI: 18-26) of previously treated TB cases were estimated to have MDR-TB; this means that in 2013, there were an estimated 71,000 (95% CI: 47,000-94,000) MDR-TB cases among notified pulmonary TB cases in this Region. The coverage of drug susceptibility testing (DST) among new and previously treated TB cases was 3% and 20%, respectively. In 2013, 11,153 cases were notified--16% of the estimated MDR-TB cases. Among the notified cases, 6926 or 62% were enrolled in treatment. Among all enrolled MDR-TB cases, 34% had second-line DST and of these, 13% were resistant to fluoroquinolones (FQ) and/or second-line injectable agents. The 2011 cohort of MDR-TB showed a 52% treatment success. Over the last five years, case notification and enrolment have increased more than five times, but the gap between notification and enrolment widened. DISCUSSION The increasing trend in detection and enrolment of MDR-TB cases demonstrates readiness to scale up programmatic management of drug-resistant TB at the country level. However, considerable challenges remain.
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178
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Lönnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Beyond UHC: monitoring health and social protection coverage in the context of tuberculosis care and prevention. PLoS Med 2014; 11:e1001693. [PMID: 25243782 PMCID: PMC4171373 DOI: 10.1371/journal.pmed.1001693] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that "No TB affected families experience catastrophic costs due to TB." High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection.
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Affiliation(s)
- Knut Lönnroth
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Philippe Glaziou
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Diana Weil
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Katherine Floyd
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Mukund Uplekar
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Mario Raviglione
- Global TB Programme, World Health Organization, Geneva, Switzerland
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