How affordable are tuberculosis diagnosis and treatment in rural China? An analysis from community and tuberculosis patient perspectives

Examining geographical inequalities for malaria outcomes and spending on malaria in 40 malaria-endemic countries, 2010-2020

BACKGROUND

While substantial gains have been made in the fight against malaria over the past 20 years, malaria morbidity and mortality are marked by inequality. The equitable elimination of malaria within countries will be determined in part by greater spending on malaria interventions, and how those investments are allocated. This study aims to identify potential drivers of malaria outcome inequality and to demonstrate how spending through different mechanisms might lead to greater health equity.

METHODS

Using the Gini index, subnational estimates of malaria incidence and mortality rates from 2010 to 2020 were used to quantify the degree of inequality in malaria burden within countries with incidence rates above 5000 cases per 100,000 people in 2020. Estimates of Gini indices represent within-country distributions of disease burden, with high values corresponding to inequitable distributions of malaria burden within a country. Time series analyses were used to quantify associations of malaria inequality with malaria spending, controlling for country socioeconomic and population characteristics.

RESULTS

Between 2010 and 2020, varying levels of inequality in malaria burden within malaria-endemic countries was found. In 2020, values of the Gini index ranged from 0.06 to 0.73 for incidence, 0.07 to 0.73 for mortality, and 0.00 to 0.36 for case fatality. Greater total malaria spending, spending on health systems strengthening for malaria, healthcare access and quality, and national malaria incidence were associated with reductions in malaria outcomes inequality within countries. In addition, government expenditure on malaria, aggregated government and donor spending on treatment, and maternal educational attainment were also associated with changes in malaria outcome inequality among countries with the greatest malaria burden.

CONCLUSIONS

The findings from this study suggest that prioritizing health systems strengthening in malaria spending and malaria spending in general especially from governments will help to reduce inequality of the malaria burden within countries. Given heterogeneity in outcomes in countries currently fighting to control malaria, and the challenges in increasing both domestic and international funding allocated to control and eliminate malaria, the efficient targeting of limited resources is critical to attain global malaria eradication goals.

Assessing the quality of tuberculosis care using routine surveillance data: a process evaluation employing the Zero TB Indicator Framework in Mongolia

OBJECTIVES

To evaluate the feasibility of the Zero TB Indicator Framework as a tool for assessing the quality of tuberculosis (TB) case-finding, treatment and prevention services in Mongolia.

SETTING

Primary health centres, TB dispensaries, and surrounding communities in four districts of Mongolia.

DESIGN

Three retrospective cross-sectional cohort studies, and two longitudinal studies each individually nested in one of the cohort studies.

PARTICIPANTS

15 947 community members from high TB-risk populations; 8518 patients screened for TB in primary health centres and referred to dispensaries; 857 patients with index TB and 2352 household contacts.

PRIMARY AND SECONDARY OUTCOME MEASURES

14 indicators of the quality of TB care defined by the Zero TB Indicator Framework and organised into three care cascades, evaluating community-based active case-finding, passive case-finding in health facilities and TB screening and prevention among close contacts; individual and health-system predictors of these indicators.

RESULTS

The cumulative proportions of participants receiving guideline-adherent care varied widely, from 96% for community-based active case-finding, to 79% for TB preventive therapy among household contacts, to only 67% for passive case-finding in primary health centres and TB dispensaries (range: 29%-80% across districts). The odds of patients completing active TB treatment decreased substantially with increasing age (aOR: 0.76 per decade, 95% CI: 0.71 to 0.83, p<0.001) and among men (aOR: 0.56, 95% CI: 0.36 to 0.88, p=0.013). Contacts of older index patients also had lower odds of initiating and completing of TB preventive therapy (aOR: 0.60 per decade, 95% CI: 0.38 to 0.93, p=0.022).

CONCLUSIONS

The Zero TB Framework provided a feasible and adaptable approach for using routine surveillance data to evaluate the quality of TB care and identify associated individual and health system factors. Future research should evaluate strategies for collecting process indicators more efficiently; gather qualitative data on explanations for low-quality care; and deploy quality improvement interventions.

How to Effectively Identify Patients With Rifampin-Resistant Tuberculosis in China: Perspectives of Stakeholders Among Service Providers

To evaluate China's current rifampin-resistant tuberculosis (RR-TB) screening strategy from stakeholders' perspectives, the perceptions, attitudes, and interests of 245 stakeholders from three eastern, central, and western China provinces on RR-TB screening strategies, were investigated through stakeholder survey and interview. The attitudes toward three RR-TB screening strategies were statistically different: inclination to choose who to screen (Z = 98.477; P < 0.001), funding for rapid diagnostic technology screening either by reimbursed health insurance or directly subsidized financial assistance (Z = 4.142, P < 0.001), and respondents' attitude during RR-TB screening implementation levels (Z = 2.380, P = 0.017). In conclusion, RR-TB screening scope could be expanded by applying rapid diagnostic technologies. Provinces with different economic status could adjust their screening policies accordingly.

The effects of family, society and national policy support on treatment adherence among newly diagnosed tuberculosis patients: a cross-sectional study

Background

Non-adherence to tuberculosis (TB) treatment is the most important cause of poor TB outcomes, and improving support for TB patients is a primary priority for governments, but there has been little research on the effects of family, social and national policy support factors on TB treatment adherence. The current study evaluated treatment adherence among newly diagnosed TB patients in Dalian, north-eastern China, and determined the effects of family, society, and national policy support factors on treatment adherence.

Methods

A cross-sectional survey was conducted among newly diagnosed TB patients treated at the outpatient department of Dalian Tuberculosis Hospital from September 2019 to January 2020. Data were collected using a questionnaire that measured medication adherence, family support, social support, and national policy support and so on. Differences between groups were assessed using Chi-square tests and Fisher’s exact tests. Ordinal logistic regression analysis was used to determine the predictors of adherence.

Results

A total of 481 newly diagnosed TB patients were recruited, of whom 45.7% had good adherence, and 27.4 and 26.8% had moderate and low adherence, respectively. Patients who had family members who frequently supervised medication (OR:0.34, 95% CI:0.16–0.70), family members who often provided spiritual encouragement (OR:0.13, 95% CI:0.02–0.72), a good doctor-patient relationship (OR:0.61, 95% CI:0.40–0.93), more TB-related knowledge (OR:0.49, 95% CI:0.33–0.72) and a high need for TB treatment policy support (OR:0.38, 95% CI:0.22–0.66) had satisfactory medication adherence. However, patients who had a college degree or higher (OR:1.69, 95% CI:1.04–2.74) and who suffered adverse drug reactions (OR:1.45, 95% CI:1.00–2.11) were more likely to have lower adherence.

Conclusions

Our findings suggested that non-adherence was high in newly diagnosed TB patients. Patients who had family members who frequently supervised medication and provided spiritual encouragement and a good doctor-patient relationship and TB-related knowledge and a high need for policy support contributed to high adherence. It is recommended to strengthen medical staff training and patient and family health education and to increase financial support for improving adherence.

What contributes to medical debt? Evidence from patients in rural China

BACKGROUND

Rural households in developing countries usually have severe medical debt due to high out-of-pocket (OOP) payments, which contributes to bankruptcy. China implemented the critical illness insurance (CII) in 2012 to decrease patients' medical expenditure. This paper aimed to explore the medical debt of rural Chinese patients and its influencing factors.

METHODS

A questionnaire survey of health expenditures and medical debt was conducted in two counties of Central and Western China in 2017. Patients who received CII were used as the sample on the basis of multi-stage stratified cluster sampling. Descriptive statistics and multivariate analysis of variance were used in all data. A two-part model was used to evaluate the occurrence and extent of medical debt.

RESULTS

A total of 826 rural patients with CII were surveyed. The percentages of patients incurring medical debt exceeded 50% and the median debt load was 20,000 Chinese yuan (CNY, 650 CNY = US$100). Financial assistance from kin (P < 0.001) decreased the likelihood of medical debt. High inpatient expenses (IEs, P < 0.01), CII reimbursement ratio (P < 0.001), and non-direct medical costs (P < 0.001) resulted in increased medical debt load.

CONCLUSIONS

Medical debt is still one of the biggest problems in rural China. High IEs, CII reimbursement ratio, municipal or high-level hospitals were the risk determinants of medical debt load. Financial assistance from kin and household income were the protective factors. Increasing service capability of hospitals in counties could leave more patiemts in county-level and township hospitals. Improving CII with increased reimbursement rate may also be issues of concern.

Factors associated with catastrophic total costs due to tuberculosis under a designated hospital service model: a cross-sectional study in China

Background

Certain districts and counties in China designated local general hospital as the designated hospital for tuberculosis (TB) management after the promulgation of the Law of Practicing Physicians in 2009. To our knowledge, there is limited research on catastrophic payments of TB patients under this service model, often with inconsistent conclusions. In addition, there has been no published studies from China using the updated 2018 World Health Organization (WHO) definition of catastrophic total costs due to TB. This study used the latest criterion recommended by the WHO to analyze the incidence of catastrophic total costs for households affected by TB under the designated hospital model and explore its influencing factors.

Methods

A cross-sectional analysis was carried out in all ten designated hospitals in Ningbo, China. Eligible pulmonary TB cases confirmed by sputum culture of Mycobacterium tuberculosis were recruited and surveyed from September 2018 to October 2018. We evaluated catastrophic total costs using total costs for TB treatment exceeding 20% of the household’s annual pre-TB income. A sensitivity analysis was performed while varying the thresholds. The least absolute shrinkage and selection operator (LASSO) regression were applied to select variables, and multiple logistic regression analysis were used to identify the determinants of catastrophic total costs.

Results

A total of 672 patients were included, with a median age of 41 years old. The rate of catastrophic total costs of surveyed households was 37.1%, and that of households affected by MDR was 69.6%. Medical cost accounted for more than 60% of the total cost. 57.7% cases were hospitalized. The hospitalization rates of patients with no comorbidities, no severe adverse drug reactions, and rifampin-sensitive TB were 53.9, 54.9, and 55.3%, respectively. Patients in the poorest households had the highest hospitalization rates (Q1:54.8%, Q2:61.4%, Q3:52.2%, Q4:49.5%, Q5:69.7%, P = 0.011) and the highest incidence of severe adverse drug reactions (Q1:29.6%, Q2:19.6%, Q3:28.0%, Q4:33.7%, Q5:35.3%, P = 0.034). Factors such as elderly, minimum living security, unemployed before or after illness, poor economic status, seeking medical care outside the city, hospitalization, absence of local basic medical insurance coverage and MDR were positively associated with catastrophic costs.

Conclusion

Substantial proportions of patients and households affected by pulmonary TB faced catastrophic economic risks in Ningbo, China. The existing policies that focus on expanding the coverage of basic medical insurance and economic protection measures (such as cash transfers to compensate low-income households for direct non-medical costs and income loss) might be insufficient. Tailored program that mitigate inappropriate healthcare and address equity of care delivery are worthy of attention.

The Effect of an Innovative Financing and Payment Model for Tuberculosis Patients on Health Service Utilization in China: Evidence from Hubei Province of China

Background: Tuberculosis (TB) remains a major social and public health problem in China. The "China-Gates TB Project" started in 2012, and one of its objectives was to reduce the financial burden on TB patients and to improve access to quality TB care. The aims of this study were to determine if the project had positive impacts on improving health service utilization. Methods: The 'China-Gates TB Project' was launched in Yichang City (YC), Hubei Province in April 2014 and ended in March 2015, lasting for one year. A series of questionnaire surveys of 540 patients were conducted in three counties of YC at baseline and final evaluations. Inpatient and outpatient service utilization were assessed before and after the program, with descriptive statistics. Propensity score matching was used to evaluate the impact of the China-Gates TB Project on health service utilization by minimizing the differences in the other characteristics of baseline and final stage groups. Focus group discussions (FGDs) were held to further enrich the results. Results: A total of 530 patients were included in this study. Inpatient rates significantly increased from 33.5% to 75.9% overall (p < 0.001), with the largest increase occurring for low income patients. Outpatient visits increased from 4.6 to 5.6 (p < 0.001), and this increase was also greatest for the poorest patients. Compared with those who lived in developed counties, the overall increase in outpatient visits for illness in the remote Wufeng county was higher. Conclusions: The China-Gates TB Project has effectively improved health service utilization in YC, and poor patients benefited more from it. TB patients in remote underdeveloped counties are more likely to increase the use of outpatient services rather than inpatient services. There is a need to tilt policy towards the poor, and various measures need to be in place in order to ensure health services utilization in undeveloped areas.

Pathways to care for patients in Pakistan experiencing signs or symptoms of breast cancer

Multiple social and financial barriers exist to breast cancer detection in Pakistan, which may cause a delay in seeking care and the final diagnosis. This analytical study documents the pathways and time courses associated with referral to diagnostic centres to evaluate the clinical signs and symptoms of breast cancer. This report also verifies the association between socio-demographic and clinical indicators concerning the length of time spent before reaching diagnostic facilities. A purposive sample of 200 patients was selected from two tertiary care hospitals in Lahore, Pakistan, for the interviews. Descriptive statistics (that is, percentages, frequencies, and measures of central tendencies) and a multiple linear regression model were used to achieve the study objectives. The descriptive model showed 31-128 days interval between a patient's awareness of a clinical sign or symptom and receiving care. The healthcare system, including traditional healers, took from 7 to 194 days, and the time to diagnosis ranged from 15 to 30 days. Pain severity, larger tumour size, lack of clinical improvement, and the desire to obtain better treatment were reasons given for seeking care, but lack of awareness and fear of financial burden related to accessing healthcare facilities were identified as barriers. Moreover, socio-demographic and other predictive clinical factors were potentially associated with and substantially influenced the likelihood of the increased length of breast cancer patients' time to reach diagnostic centres. In conclusion, referrals by multiple healthcare providers, especially traditional healers and general practitioners, was a significant predictor for delay in diagnosis. Therefore, increased awareness and a responsive healthcare system may reduce the time from the recognition of symptoms to the early detection of breast cancer among women, thus improving outcomes in a developing country.

Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China

BACKGROUND

Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden.

METHODS

Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding.

RESULTS

Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable.

CONCLUSIONS

Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.

How does the pharmaceutical industry influence prescription? A qualitative study of provider payment incentives and drug remunerations in hospitals in Shanghai

Over-prescription has become one major problem in China's health care sector. Incorporating interview data from hospitals in Shanghai, this paper provided empirical evidence on how the process of over-prescription was carried out in day-to-day clinical settings, and demonstrates various mechanisms that allow over-prescription to continue vigorously in the context of the Chinese health care system. In particular, this study identified four levels of incentives that over-prescription was carried out: hospital, medical department, doctors and pharmaceutical companies. Due to the insufficient funding from the government and rising operational costs, hospitals had to rely on the sales of drugs and provision of medical services to survive. This funding pressure then transferred to specific revenue targets for medical departments. A combination of incentives, including drug remunerations, bonus system, low pay and high workloads motivated over-prescription at doctor level. At pharmaceutical company level, high profits of pharmaceuticals products as well as lack of emphasis on efficacy of drugs led to under-table payments and illicit drug remunerations. The study argued that the way that the Chinese health care system operates was based on the profit-seeking principle rather than on fulfilling its social functions, and called for a systematic reform of provider incentives to eradicating the problem of over-prescription.

Drug-resistant tuberculosis control in China: progress and challenges

BACKGROUND

China has the second highest caseload of multidrug-resistant tuberculosis (MDR-TB) in the world. In 2009, the Chinese government agreed to draw up a plan for MDR-TB prevention and control in the context of a comprehensive health system reform launched in the same year.

DISCUSSION

China is facing high prevalence rates of drug-resistant TB and MDR-TB. MDR-TB disproportionally affects the poor rural population and the highest rates are in less developed regions largely due to interrupted and/or inappropriate TB treatment. Most households with an affected member suffer a heavy financial burden because of a combination of treatment and other related costs. The influential Global Fund programme for MDR-TB control in China provides technical and financial support for MDR-TB diagnosis and treatment. However, this programme has a fixed timeline and cannot provide a long term solution. In 2009, the Bill and Melinda Gates Foundation, in cooperation with the National Health and Family Planning Commission of China, started to develop innovative approaches to TB/MDR-TB management and case-based payment mechanisms for treatment, alongside increased health insurance benefits for patients, in order to contain medical costs and reduce financial barriers to treatment. Although these efforts appear to be in the right direction, they may not be sufficient unless (a) domestic sources are mobilized to raise funding for TB/MDR-TB prevention and control and (b) appropriate incentives are given to both health facilities and their care providers. Along with the on-going Chinese health system reform, sustained government financing and social health protection schemes will be critical to ensure universal access to appropriate TB treatment in order to reduce risk of developing MDR-TB and systematic MDR-TB treatment and management.

The impact of the new cooperative medical scheme on financial burden of tuberculosis patients: evidence from six counties in China

Background

Tuberculosis (TB) patients in China encounter heavy financial burdens throughout the course of their treatment and it is unclear how China’s health insurance systems affect the alleviation of this burden under the integrated approach. This study aimed to measure reimbursement for TB services under the New Cooperative Medical Scheme (NCMS) in rural China and to evaluate changes in catastrophic health expenditure (CHE) caused by the reimbursement policies.

Methods

Reimbursement data were obtained from routine data systems for the NCMS in Yichang (YC) and Hanzhong (HZ). 1884 TB inpatients reimbursed by NCMS from 2010 to 2012 were included. Household surveys were conducted. A total of 494 TB patients under the NCMS were selected in this paper. 12 Focus Group Discussions (FGDs) were held. We measured the impact of the NCMS by counterfactual analysis, which analyzed the financial burden alleviation. Equity was assessed by Concentration Index (CI), and disaggregated by project sites.

Results

TB inpatients were reimbursed with an effective reimbursement rate of 57.3 %. Average out-of-pocket (OOP) payments for outpatient and inpatient services after diagnosis were 1413 yuan and 430 yuan, and 3572 yuan and 3013 yuan in YC and HZ, respectively. The reimbursement level for TB outpatient care after diagnosis was very low due to a limited outpatient quota. TB patients in HZ incurred higher effective reimbursement rates, but the incidence of CHE remained higher. The reduction of CHE incidence after the NCMS showed no difference statistically (P > 0.05). The severity of CHE was alleviated slightly. CIs after reimbursement were all below zero and their absolute values were higher than those before reimbursement.

Conclusions

Low reimbursement for TB patients could lead to heavy financial burden. Poor TB patients incurred high rates of CHE. The NCMS was found to be a protective factor for CHE, but the impact was modest and the equity of CHE did not improve. The NCMS reimbursement policies should be improved in the future to include a more comprehensive coverage of care. Supplemental programs may be necessary to expand coverage for TB care.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-015-0094-5) contains supplementary material, which is available to authorized users.

Non-medical financial burden in tuberculosis care: a cross-sectional survey in rural China

Background

Treatment of tuberculosis (TB) in China is partially covered by national programs and health insurance schemes, though TB patients often face considerable medical expenditures. For some, especially those from poorer households, non-medical costs, such as transport, accommodation, and nutritional supplementation may be a substantial additional burden. In this article we aim to evaluate these non-medical costs induced by seeking TB care using data from a large scale cross-sectional survey.

Methods

A total of 797 TB cases from three cities were randomly selected using a stratified cluster sampling design. Inpatient medical costs, outpatient medical costs, and direct non-medical costs related to TB treatment were collected using in-person interviews by trained interviewers. Mean and median non-medical costs for different sub-groups were calculated and compared using Kruskal-Wallis and Mann–Whitney U tests. Regression analysis was conducted to assess the influence of different patient characteristics on total non-medical cost.

Results

The median non-medical cost was RMB 1429, with interquartile range RMB 424–2793. The median non-medical costs relating to inpatient treatment, outpatient treatment, and additional nutrition supplementation were RMB 540, 91, and 900, respectively. Of the 797 cases, 20 % reported catastrophic expenditure on non-medical costs. Statistically significant differences were detected between different cities, age groups, geographical locations, inpatient/outpatient care, education levels and family income groups.

Conclusions

Non-medical costs relating to TB treatment are a serious financial burden for many TB patients. Financial assistance that can limit this burden is urgently needed during the treatment period, especially for the poor.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0101-5) contains supplementary material, which is available to authorized users.

Implementing a "free" tuberculosis (TB) care policy under the integrated model in Jiangsu, China: practices and costs in the real world

Background

In the 1990s, China introduced a “free” tuberculosis (TB) care policy under the national TB control program. Recently, as a part of a new TB diagnosis and treatment model, it has been recommended that the integrated model scale up. This paper examines whether or not TB designated hospitals in the selected project sites have provided TB care according to the national and local guidelines, and analyzes the actual practices and expenditures involved in completing TB treatment. It also explores the reasons why “free” TB care in China cannot be effectively implemented under the integrated model.

Methods

This study was conducted in three counties of Zhenjiang city, Jiangsu province. Mixed methods were used, which comprised reviewing the national and local TB control guidelines, conducting TB patient surveys, collecting TB inpatient and outpatient hospital records, and conducting qualitative interviews with stakeholders. Descriptive statistics were used for quantitative data analysis across counties and in order to compare patients who received only outpatient care and those who received both outpatient and inpatient care. The chi-square test and analysis of variance were performed where necessary. Qualitative data were analyzed using the framework approach.

Results

Although the national TB care guidelines recommend outpatient care as a basis for TB treatment in China, we found high hospital admission rates for TB patients ranging from 39 % in Yangzhong county to 83 % in Dantu county. Almost all outpatient TB patients paid for lab tests and over 80 % paid for liver protection drugs and around 70 % paid for image examinations. These three components accounted for three-quarters of the total outpatient expenditure. For patients who received only outpatient care, the total expenditure upon completion of TB treatment was on average 1,135 Chinese yuan. For patients who received outpatient and inpatient care, the total expenditure upon completion of TB treatment was 11,117 Chinese yuan.

Conclusion

The “free” TB care policy under the integrated model has not been effectively implemented in China. There has been substantial spending on non-recommended services, examinations, and drugs for TB treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0099-8) contains supplementary material, which is available to authorized users.

Factors that associated with TB patient admission rate and TB inpatient service cost: a cross-sectional study in China

Background

China has recently adopted the “TB designated hospital model” to improve the quality of tuberculosis (TB) treatment and patient management. Considering that inpatient service often results in high patient financial burden, and therefore influences patient adherence to treatment, it is critical to better understand the TB patient admission rate and TB inpatient service cost, as well as their influential factors in this new model.

Methods

Quantitative and qualitative studies were conducted in two cities, Hanzhong in Shaanxi Province and Zhenjiang in Jiangsu Province, in China. Quantitative data were obtained from a sample survey of 533 TB patients and TB inpatient records from 2010–2012 in six county designated hospitals. Qualitative information was obtained through interviews with key stakeholders (40 key informant interviews, 14 focus group discussions) and reviews of health policy documents in study areas. Both univariate and multivariate statistical analyses were applied for the quantitative analysis, and the thematic framework approach was applied for the qualitative analysis.

Results

The TB patient admission rates in Zhenjiang and Hanzhong were 54.8 and 55.9 %, respectively. Qualitative analyses revealed that financial incentives, misunderstanding of infectious disease control and failure of health insurance regulations were the key factors associated with the admission rates and medical costs. Quantitative analyses found differences in hospitalization rate existed among patients with different health insurance and patients from different counties. Average medical costs for TB inpatients in Jurong and Zhenba were 7,215 CNY and 4,644 CNY, which was higher than the 5,500 CNY and 3,800 CNY limits set by the New Rural Cooperative Medical System. No differences in medical cost or length of stay were found between patients with and without comorbidities in county-level hospitals.

Conclusions

TB patient admission rates and inpatient service costs were relatively high. Studies of related factors indicated that a package of interventions, including health education programs, reform of health insurance regulations and improvement of TB treatment guidelines, are urgently required to ensure that TB patients receive appropriate care.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0097-x) contains supplementary material, which is available to authorized users.

Are free anti-tuberculosis drugs enough? An empirical study from three cities in China

Background

Tuberculosis (TB) patients in China still face a number of barriers in seeking diagnosis and treatment. There is evidence that the economic burden on TB patients and their households discourages treatment compliance.

Methods

A cross-sectional study was conducted in three cities of China. Patients were selected using probability proportional to size (PPS) cluster sampling of rural townships or urban streets, followed by list sampling from a patient register. Data were collected using a questionnaire survey, key informant interviews and focus group discussions with TB patients to gain an understanding of the economic burden of TB and implications of this burden for treatment compliance.

Results

A total of 797 TB patients were surveyed, of which 60 were interviewed in-depth following the survey. More than half had catastrophic health expenditure. TB patients with higher household incomes were less likely to report non-compliance (OR 0.355, 95 % CI 0.140–0.830) and patients who felt that the economic burden relating to TB treatment was high more likely to report non-compliance (OR 3.650, 95 % CI 1.278–12.346). Those who had high costs for transportation, lodging and food were also more likely to report non-compliance (OR 4.150, 95 % CI 1.804–21.999). The findings from the qualitative studies supported those from the survey.

Conclusion

The economic burden associated with seeking diagnosis and treatment remains a barrier for TB patients in China. Reducing the cost of treatment and giving patients subsidies for transportation, lodging and food is likely to improve treatment compliance. Improving doctors’ salary system to cut off the revenue-oriented incentive, and expanding current insurance’s coverage can be helpful to reduce patients’ actual burden or anticipated burden. Future research on this issue is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-015-0080-y) contains supplementary material, which is available to authorized users.

Patient delay in the diagnosis and treatment of tuberculosis in China: findings of case detection projects

OBJECTIVE

1) To assess patient delay among new smear-positive pulmonary tuberculosis (PTB) patients in accessing health services in seven FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) projects from 2003 to 2008 in China; 2) to compare treatment delay by province; and 3) to assess factors associated with delay.

METHOD

Records of new smear-positive PTB patients were reviewed. Data sources were the consultation book, laboratory register, patient record, treatment card and the PWLAHS (people with limited access to health services) evaluation form. Data were collected using a standard questionnaire, cross-checked by staff from the sites and by the International Union Against Tuberculosis and Lung Disease (The Union) and analysed by The Union.

RESULTS

Of the 75 401 new smear-positive PTB patients included in the study, 63-89% were PWLAHS. The average gross domestic product of the project sites and at national level were respectively US$557 and US$998. The median patient delay was 93 days (range 68-128). Delays were longer among females, older patients, rural residents and PWLAHS. Delayed access to health services was significantly associated with a greater number of symptoms.

CONCLUSION

Patient delay in accessing health care in China was lengthy; TB care and control needs to be improved.

Costs to Health Services and the Patient of Treating Tuberculosis: A Systematic Literature Review

BACKGROUND

Novel tuberculosis (TB) drugs and the need to treat drug-resistant tuberculosis (DR-TB) are likely to bring about substantial transformations in TB treatment in coming years. An evidence base for cost and cost-effectiveness analyses of these developments is needed.

OBJECTIVE

Our objective was to perform a review of papers assessing provider-incurred as well as patient-incurred costs of treating both drug-susceptible (DS) and multidrug-resistant (MDR)-TB.

METHODS

Five databases (EMBASE, Medline, the National Health Service Economic Evaluation Database, the Cost-Effectiveness Analysis Registry, and Latin American and Caribbean Health Services Literature) were searched for cost and economic evaluation full-text papers containing primary DS-TB and MDR-TB treatment cost data published in peer-reviewed journals between January 1990 and February 2015. No language restrictions were set. The search terms were a combination of 'tuberculosis', 'multidrug-resistant tuberculosis', 'cost', and 'treatment'. In the selected papers, study methods and characteristics, quality indicators and costs were extracted into summary tables according to pre-defined criteria. Results were analysed according to country income groups and for provider costs, patient costs and productivity losses. All values were converted to $US, year 2014 values, so that studies could be compared.

RESULTS

We selected 71 treatment cost papers on DS-TB only, ten papers on MDR-TB only and nine papers that included both DS-TB and MDR-TB. These papers provided evidence on the costs of treating DS-TB and MDR-TB in 50 and 16 countries, respectively. In 31 % of the papers, only provider costs were included; 26 % included only patient-incurred costs, and the remaining 43 % estimated costs incurred by both. From the provider perspective, mean DS-TB treatment costs per patient were US$14,659 in high-income countries (HICs), US$840 in upper middle-income countries (UMICs), US$273 in lower middle-income (LMICs), and US$258 in low-income countries (LICs), showing a strong positive correlation. The respective costs for treating MDR-TB were US$83,365, US$5284, US$6313 and US$1218. Costs incurred by patients when seeking treatment for DS-TB accounted for an additional 3 % of the provider costs in HICs. A greater burden was seen in the other income groups, increasing the costs of DS-TB treatment by 72 % in UMICs, 60 % in LICs and 31 % in LMICs. When provider costs, patient costs and productivity losses were combined, productivity losses accounted for 16 % in HICs, 29 % in UMICs, 40 % in LMICs and 38 % in LICs.

CONCLUSION

Cost data for MDR-TB treatment are limited, and the variation in delivery mechanisms, as well as the rapidly evolving diagnosis and treatment regimens, means that it is essential to increase the number of studies assessing the cost from both provider and patient perspectives. There is substantial evidence available on the costs of DS-TB treatment from all regions of the world. The patient-incurred costs illustrate that the financial burden of illness is relatively greater for patients in poorer countries without universal healthcare coverage.

Is tuberculosis treatment really free in China? A study comparing two areas with different management models

Objective

China has implemented a free-service policy for tuberculosis. However, patients still have to pay a substantial proportion of their annual income for treatment of this disease. This study describes the economic burden on patients with tuberculosis; identifies related factors by comparing two areas with different management models; and provides policy recommendation for tuberculosis control reform in China.

Methods

There are three tuberculosis management models in China: the tuberculosis dispensary model, specialist model and integrated model. We selected Zhangjiagang (ZJG) and Taixing (TX) as the study sites, which correspond to areas implementing the integrated model and dispensary model, respectively. Patients diagnosed and treated for tuberculosis since January 2010 were recruited as study subjects. A total of 590 patients (316 patients from ZJG and 274 patients from TX) were interviewed with a response rate of 81%. The economic burden attributed to tuberculosis, including direct costs and indirect costs, was estimated and compared between the two study sites. The Mann-Whitney U Test was used to compare the cost differences between the two groups. Potential factors related to the total out-of-pocket costs were analyzed based on a step-by-step multivariate linear regression model after the logarithmic transformation of the costs.

Results

The average (median, interquartile range) total cost was 18793.33 (9965, 3200-24400) CNY for patients in ZJG, which was significantly higher than for patients in TX (mean: 6598.33, median: 2263, interquartile range: 983–6688) (Z = 10.42, P < 0.001). After excluding expenses covered by health insurance, the average out-of-pocket costs were 14304.4 CNY in ZJG and 5639.2 CNY in TX. Based on the multivariable linear regression analysis, factors related to the total out-of-pocket costs were study site, age, number of clinical visits, residence, diagnosis delay, hospitalization, intake of liver protective drugs and use of the second-line drugs.

Conclusion

Under the current “free of diagnosis and treatment” policy, the financial burden remains heavy on tuberculosis patients. Policy makers need to consider appropriate steps to lessen the burden of out-of-pocket costs for tuberculosis patients in China and how best to improve service delivery for poor patients.

Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru

BACKGROUND

Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB-affected households) may worsen poverty and health. Extreme TB-associated costs have been termed "catastrophic" but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs.

METHODS AND FINDINGS

From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2-4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%-43%) in the least-poor houses versus 48% (95% CI = 36%-50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs ≥20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%-61%] versus 38% [95% CI = 34%-41%], p<0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7-15], p<0.001), previous TB (OR = 2.1 [95% CI = 1.3-3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00-1.01], p = 0.02), and catastrophic costs (OR = 1.7 [95% CI = 1.1-2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%-28%), similar to that of MDR TB (20% [95% CI = 14%-25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥10% or ≥15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain "dis-saving" variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients.

CONCLUSIONS

Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary.

Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review

In order to inform the development of appropriate strategies to improve financial risk protection, we conducted a systematic literature review of the financial burden of tuberculosis (TB) faced by patients and affected families. The mean total costs ranged from $55 to $8198, with an unweighted average of $847. On average, 20% (range 0-62%) of the total cost was due to direct medical costs, 20% (0-84%) to direct non-medical costs, and 60% (16-94%) to income loss. Half of the total cost was incurred before TB treatment. On average, the total cost was equivalent to 58% (range 5-306%) of reported annual individual and 39% (4-148%) of reported household income. Cost as percentage of income was particularly high among poor people and those with multidrug-resistant TB. Commonly reported coping mechanisms included taking a loan and selling household items. The total cost of TB for patients can be catastrophic. Income loss often constitutes the largest financial risk for patients. Apart from ensuring that healthcare services are fairly financed and delivered in a way that minimises direct and indirect costs, there is a need to ensure that TB patients and affected families receive appropriate income replacement and other social protection interventions.

Population aging and migrant workers: bottlenecks in tuberculosis control in rural China

Background

Tuberculosis is a serious global health problem. Its paradigms are shifting through time, especially in rapidly developing countries such as China. Health providers in China are at the forefront of the battle against tuberculosis; however, there are few empirical studies on health providers' perspectives on the challenges they face in tuberculosis control at the county level in China. This study was conducted among health providers to explore their experiences with tuberculosis control in order to identify bottlenecks and emerging challenges in controlling tuberculosis in rural China.

Methods

A qualitative approach was used. Semi-structured, in-depth interviews were conducted with 17 health providers working in various positions within the health system of one rural county (ZJG) of China. Data were analyzed based on thematic content analysis using MAXQDA 10 qualitative data analysis software.

Results

Health providers reported several problems in tuberculosis control in ZJG county. Migrant workers and the elderly were repeatedly documented as the main obstacles in effective tuberculosis control in the county. At a personal level, doctors showed their frustration with the lack of new drugs for treating tuberculosis patients, and their opinions varied regarding incentives for referring patients.

Conclusion

The results suggest that several problems still remain for controlling tuberculosis in rural China. Tuberculosis control efforts need to make reaching the most vulnerable populations a priority and encourage local health providers to adopt innovative practices in the local context based on national guidelines to achieve the best results. Considerable changes in China's National Tuberculosis Control Program are needed to tackle these emerging challenges faced by health workers at the county level.

Impacts of the "transport subsidy initiative on poor TB patients" in Rural China: a patient-cohort based longitudinal study in rural China

Objective

To describe the financial burden on TB patients for transportation during treatment, and to evaluate the impacts of the “transportation subsidy initiative on poor TB patients” in rural China for improving poor patients’ access to TB treatment.

Methods

A Case-cohort of 429 TB patients was investigated through questionnaire interviews in four counties of two provinces in China. Information on the financial burden for transportation during TB diagnosis and treatment was collected. Qualitative in-depth interviews with 26 TB patients were carried out to understand their perceptions of transportation subsidy initiative.

Results

The mean transportation cost of TB medical care was 97 CNY (70 CNY in median), varying from 0 to 700 CNY. About 51% of the patients spent more than 10 CNY per round trip to the TB dispensary. Of the 429 TB patients investigated, 139 had received transportation subsidies after getting TB diagnosis; 15/139 (10.9%) showed dissatisfaction, mainly because the subsidy amount being insufficient. The income of patients receiving transportation subsidies was significantly lower than those not receiving the subsidies (p<0.05). The impression that an appropriate transportation subsidy enables patients to complete the required visits during their TB treatment was obtained after observation of over 80% of the patients.

Conclusion

The transportation subsidy plays an important role in reducing financial burden on poor TB patients for the completion of treatment. However, the coverage was limited and the amount of subsidy was not enough under the present policy. Considering the poverty of rural TB patients, a universal coverage and a rational amount of transportation subsidy should be proposed.

Patient care pathways under the model of integrating tuberculosis service with general hospitals in China

OBJECTIVE

To report care pathways of tuberculosis (TB) patients under the integrated model, where TB clinical service is provided by a general hospital instead of the TB dispensary, with the aim of providing policy recommendations for TB care reforms in China.

METHODS

Six counties implementing the integrated model were randomly selected, and 50 TB patients in each county participated in a questionnaire survey.

RESULTS

Of the 301 participants, 82 visited only the TB designated hospital. A patient visited a median of two health providers in total. The median external provider delay and internal provider delay were 1 and 0 day, respectively. The median out-of-pocket medical costs were US$379 in total; US$293 in the TB units and US$0 in other health units in the TB designated hospital. Logistic regression analyses suggested that patients who visited the primary care facilities first tended to have longer external delays (OR = 5.71) than patients who visited the other hospitals (OR = 10.16).

CONCLUSION

The integrated model is promising as it reported relatively fewer patient pathways and shorter delays than the dispensary model. However, the integrated model did not reduce patient out-of-pocket costs.

Comparing patient care seeking pathways in three models of hospital and TB programme collaboration in China

Background

Public hospitals in China play an important role in tuberculosis (TB) control. Three models of hospital and TB control exist in China. The dispensary model is the most common one in which a TB dispensary provides both clinical and public health care. The specialist model is similar to the former except that a specialist TB hospital is located in the same area. The specialist hospital should treat only complicated TB cases but it also treats simple cases in practice. The integrated model is a new development to integrate TB service in public hospitals. Patients were diagnosed, treated and followed up in this public hospital in this model while the TB dispensary provides public health service as case reporting and mass education. This study aims to compare patient care seeking pathways under the three models, and to provide policy recommendation for the TB control system reform in China.

Methods

Six sites, two in each model, were selected across four provinces, with 293 newly treated uncomplicated TB patients being randomly selected.

Results

The majority (68%) of TB patients were diagnosed in hospitals. Patients in the integrated model presented the simplest care seeking pathways, with the least number of providers visited (2.2), shortest treatment delays (2 days) and the least medical expenditure (2729RMB/401USD). On the contrary, patients in the specialist model had the highest number of provider visits (4), longest treatment delays (23 days) and the highest medical expenditure (11626RMB/1710USD). Logistic regression suggested that patients who were hospitalised tended to have longer treatment delays and higher medical expenditure.

Conclusion

Specialist hospital treating uncomplicated cases not using the standard regimens posed a threat to TB control. The integrated model has shortened patient treatment pathways, and reduced patient costs; therefore, it could be considered as the direction for future reform of China’s TB control system.

Schistosomiasis control and the health system in P.R. China

Over the last sixty years advances have been made in the control of schistosomiasis in P.R. China. There are, however, difficult challenges still to be met. This paper looks at the extent to which the health system offers a positive environment for the control of the disease. It starts by tracing three phases in schistosomiasis control: disease elimination strategy through snail control (1950s-early 1980s); morbidity control strategy based on chemotherapy (mid 1980s to 2003); integrated control strategy (2004+). Each one of these phases took place in distinct policy-making environments. The paper partly draws on these phases to set out five issues of disease control and discusses them in the context of the health system and its recent trends. These cover the policy-making process, intersectoral action for health, equity and access to health services, funding for public goods and externalities, and strengthening resource management and planning. These issues form the basis of an agenda for integrating research and capacity strengthening in the Chinese health system with a view to creating a more positive enabling environment for schistosomiasis control. In so doing it is important to emphasize the role and integrity of the public sector against its commercialization, the underlying value of equity, a systems wide perspective, and the role of advocacy.

Does the integration of TB medical services in the general hospital improve the quality of TB care? Evidence from a case study in China

BACKGROUND

Moving the clinical services from tuberculosis (TB) dispensary to the integrated county hospital (called integrated approach) has been practiced in China; however, it is unknown the quality of TB care in the integrated approach and in the dispensary approach.

METHODS

A total of 202 new TB patients were investigated using structured questionnaires in three counties implementing the integrated approach and one county implementing the dispensary approach. The quality of TB care is measured based on success rate of treatment, medical expenditure, health system delay and second-line drug use.

RESULTS

The integrated approach showed a high success treatment rate. The medical expenditure in the integrated approach was USD 432, significantly lower than that in the dispensary approach (Z = -5.771, P < 0.001). The integrated approach had a shorter health system delay (5 days) than the dispensary approach (32 days). Twenty-six percent of patients in integrated hospitals were prescribed with second-line TB drugs, significantly lower than that in the TB dispensary (47%, χ(2) = 7.452, P = 0.006). However, the medical expenditure, use of second-line anti-TB drug and liver-protection drugs indeed varied greatly across the three integrated hospitals.

CONCLUSIONS

The integrated approach showed better quality of TB care, but the performance of the integrated hospitals varied greatly. A method to standardize TB treatment and management of this approach is urgent.

Factors associated with survival among adults with HIV-associated TB in Guangxi, China: a retrospective cohort study

Aim: Although China has the second highest burden of TB in the world and faces a burgeoning HIV epidemic, the epidemiology and 12-month clinical outcomes of HIV-infected TB patients have not previously been reported. Methods: We reviewed records of all HIV-infected adults diagnosed with culture-confirmed TB from four HIV clinics in Guangxi, China from August 2006 to December 2008. Factors associated with patients’ survival within 12 months after TB diagnosis were evaluated in Cox proportional hazards models. Results: Among the 201 patients included, 47 (23%) died within 12 months. Median CD4 count at TB diagnosis was 37 cells/mm3 (interquartile range: 16–102). Receiving HAART (adjusted hazard ratio [AHR]: 4.2; 95% CI: 1.6–10.8), receiving TB treatment (AHR: 9.0; 95% CI: 1.5–53.5) and baseline BMI ≥ 18.5 (AHR: 8.4; 95% CI: 1.9–35.8) were independently associated with survival. Among 171 (85%) patients who received TB treatment, receiving HAART (HR: 5.1; 95% CI: 2.4–10.7) was the only factor significantly associated with survival. Conclusion: HIV-infected Chinese patients diagnosed with TB in Guangxi are at high risk of death within 12 months, a risk that is strongly mitigated by antiretroviral therapy. Improving survival from HIV-associated TB in China will require the integration of TB and HIV programs to improve access to treatment for both diseases.

Modelling the impacts of new diagnostic tools for tuberculosis in developing countries to enhance policy decisions

The introduction and scale-up of new tools for the diagnosis of Tuberculosis (TB) in developing countries has the potential to make a huge difference to the lives of millions of people living in poverty. To achieve this, policy makers need the information to make the right decisions about which new tools to implement and where in the diagnostic algorithm to apply them most effectively. These decisions are difficult as the new tools are often expensive to implement and use, and the health system and patient impacts uncertain, particularly in developing countries where there is a high burden of TB. The authors demonstrate that a discrete event simulation model could play a significant part in improving and informing these decisions. The feasibility of linking the discrete event simulation to a dynamic epidemiology model is also explored in order to take account of longer term impacts on the incidence of TB. Results from two diagnostic districts in Tanzania are used to illustrate how the approach could be used to improve decisions.

Tuberculosis diagnostics and biomarkers: needs, challenges, recent advances, and opportunities

Tuberculosis is unique among the major infectious diseases in that it lacks accurate rapid point-of-care diagnostic tests. Failure to control the spread of tuberculosis is largely due to our inability to detect and treat all infectious cases of pulmonary tuberculosis in a timely fashion, allowing continued Mycobacterium tuberculosis transmission within communities. Currently recommended gold-standard diagnostic tests for tuberculosis are laboratory based, and multiple investigations may be necessary over a period of weeks or months before a diagnosis is made. Several new diagnostic tests have recently become available for detecting active tuberculosis disease, screening for latent M. tuberculosis infection, and identifying drug-resistant strains of M. tuberculosis. However, progress toward a robust point-of-care test has been limited, and novel biomarker discovery remains challenging. In the absence of effective prevention strategies, high rates of early case detection and subsequent cure are required for global tuberculosis control. Early case detection is dependent on test accuracy, accessibility, cost, and complexity, but also depends on the political will and funder investment to deliver optimal, sustainable care to those worst affected by the tuberculosis and human immunodeficiency virus epidemics. This review highlights unanswered questions, challenges, recent advances, unresolved operational and technical issues, needs, and opportunities related to tuberculosis diagnostics.

Drug-resistant tuberculosis--current dilemmas, unanswered questions, challenges, and priority needs

Tuberculosis was declared a global emergency by the World Health Organization (WHO) in 1993. Following the declaration and the promotion in 1995 of directly observed treatment short course (DOTS), a cost-effective strategy to contain the tuberculosis epidemic, nearly 7 million lives have been saved compared with the pre-DOTS era, high cure rates have been achieved in most countries worldwide, and the global incidence of tuberculosis has been in a slow decline since the early 2000s. However, the emergence and spread of multidrug-resistant (MDR) tuberculosis, extensively drug-resistant (XDR) tuberculosis, and more recently, totally drug-resistant tuberculosis pose a threat to global tuberculosis control. Multidrug-resistant tuberculosis is a man-made problem. Laboratory facilities for drug susceptibility testing are inadequate in most tuberculosis-endemic countries, especially in Africa; thus diagnosis is missed, routine surveillance is not implemented, and the actual numbers of global drug-resistant tuberculosis cases have yet to be estimated. This exposes an ominous situation and reveals an urgent need for commitment by national programs to health system improvement because the response to MDR tuberculosis requires strong health services in general. Multidrug-resistant tuberculosis and XDR tuberculosis greatly complicate patient management within resource-poor national tuberculosis programs, reducing treatment efficacy and increasing the cost of treatment to the extent that it could bankrupt healthcare financing in tuberculosis-endemic areas. Why, despite nearly 20 years of WHO-promoted activity and >12 years of MDR tuberculosis-specific activity, has the country response to the drug-resistant tuberculosis epidemic been so ineffectual? The current dilemmas, unanswered questions, operational issues, challenges, and priority needs for global drug resistance screening and surveillance, improved treatment regimens, and management of outcomes and prevention of DR tuberculosis are discussed.

Treatment adherence among sputum smear-positive pulmonary tuberculosis patients in mountainous areas in China

Background

We carried out an investigation in five provinces in China to assess treatment adherence and identify factors associated with insufficient treatment adherence in tuberculosis (TB) patients in mountainous, rural areas of China.

Methods

In each of the five provinces, all counties with > 80% mountainous area were stratified into three groups according to their gross domestic product. In each stratum, one county was randomly sampled. Study subjects were sampled from all smear positive TB cases registered in 2007 in the target counties. TB patients, village doctors, county doctors and directors of the TB prevention and control institutes were interviewed. Insufficient medication adherence was defined as taking less than 90% of anti-TB drug doses prescribed. Insufficient re-examination adherence was defined as having less than the recommended three sputum smear examinations during the treatment course.

Results

A minority of patients took drugs under direct observation: on average 29% during the intensive phase of treatment. In total, 524 TB patients were included, of whom 49 (9.4%) took less than 90% of all doses prescribed and 92 (17.6%) did not have all sputum smear examinations, with substantial variations between the provinces. In multivariable analysis, no direct observation of treatment during the intensive phase and the presence of adverse events were associated both with insufficient medication adherence and insufficient re-examination adherence. Overall, 79% of patients were adherent both to treatment and re-examinations.

Conclusions

In these remote and poor areas of China, the TB control program is not fully functioning according to the guidelines. The majority of patients are not treated under direct observation, while direct observation by health care staff was associated with better adherence, both to drug therapy and re-examinations. Insufficient adherence increases the risk of unsuccessful treatment outcomes and development of drug resistance. Measures should be taken urgently in these areas to strengthen implementation of the international Stop TB strategy.

A multi-country non-inferiority cluster randomized trial of frontloaded smear microscopy for the diagnosis of pulmonary tuberculosis

BACKGROUND

More than 50 million people around the world are investigated for tuberculosis using sputum smear microscopy annually. This process requires repeated visits and patients often drop out.

METHODS AND FINDINGS

This clinical trial of adults with cough ≥2 wk duration (in Ethiopia, Nepal, Nigeria, and Yemen) compared the sensitivity/specificity of two sputum samples collected "on the spot" during the first visit plus one sputum sample collected the following morning (spot-spot-morning [SSM]) versus the standard spot-morning-spot (SMS) scheme. Analyses were per protocol analysis (PPA) and intention to treat (ITT). A sub-analysis compared just the first two smears of each scheme, spot-spot and spot-morning. In total, 6,627 patients (3,052 SSM/3,575 SMS) were enrolled; 6,466 had culture and 1,526 were culture-positive. The sensitivity of SSM (ITT, 70.2%, 95% CI 66.5%-73.9%) was non-inferior to the sensitivity of SMS (PPA, 65.9%, 95% CI 62.3%-69.5%). Similarly, the specificity of SSM (ITT, 96.9%, 95% CI 93.2%-99.9%) was non-inferior to the specificity of SMS (ITT, 97.6%, 95% CI 94.0%-99.9%). The sensitivity of spot-spot (ITT, 63.6%, 95% CI 59.7%-67.5%) was also non-inferior to spot-morning (ITT, 64.8%, 95% CI 61.3%-68.3%), as the difference was within the selected -5% non-inferiority limit (difference ITT = 1.4%, 95% CI -3.7% to 6.6%). Patients screened using the SSM scheme were more likely to provide the first two specimens than patients screened with the SMS scheme (98% versus 94.2%, p<0.01). The PPA and ITT analysis resulted in similar results.

CONCLUSIONS

The sensitivity and specificity of SSM are non-inferior to those of SMS, with a higher proportion of patients submitting specimens. The scheme identifies most smear-positive patients on the first day of consultation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53339491. Please see later in the article for the Editors' Summary.

Patient medical costs for tuberculosis treatment and impact on adherence in China: a systematic review

Background

Charging for tuberculosis (TB) treatment could reduce completion rates, particularly in the poor. We identified and synthesised studies that measure costs of TB treatment, estimates of adherence and the potential impact of charging on treatment completion in China.

Methods

Inclusion criteria were primary research studies, including surveys and studies using qualitative methods, conducted in mainland China. We searched MEDLINE, PUBMED, EMBASE, Science Direct, HEED, CNKI to June 2010; and web pages of relevant Chinese and international organisations. Cost estimates were extracted, transformed, and expressed in absolute values and as a percentage of household income.

Results

Low income patients, defined at household or district level, pay a total of US$ 149 to 724 (RMB 1241 to 5228) for medical costs for a treatment course; as a percentage of annual household income, estimates range from 42% to 119%. One national survey showed 73% of TB patients at the time of the survey had interrupted or suspended treatment, and estimates from 9 smaller more recent studies showed that the proportion of patients at the time of the survey who had run out of drugs or were not taking them ranged from 3 to 25%. Synthesis of surveys and qualitative research indicate that cost is the most cited reason for default.

Conclusions

Despite a policy of free drug treatment for TB in China, health services charge all income groups, and costs are high. Adherence measured in cross sectional surveys is often low, and the cumulative failure to adhere is likely to be much higher. These findings may be relevant to those concerned with the development and spread of multi-drug resistant TB. New strategies need to take this into account and ensure patient adherence.

Risk factors for non-cure among new sputum smear positive tuberculosis patients treated in tuberculosis dispensaries in Yunnan, China

Background

Yunnan province in China has a high tuberculosis (TB) burden. Cure rates in general are high, but they were below the target of 85% in 26 out of 129 counties in 2005. In these 26 counties we assessed which patient-related and treatment-related factors were associated with non-cure.

Methods

We conducted a prospective cohort study. Smear positive pulmonary TB patients treated at the local Center for Disease Control and Prevention (CDC) were interviewed before start of treatment and during the fifth month of treatment using structured questionnaires. Information on treatment outcome was extracted from patient records. Patients cured at the end of treatment were compared to patients with unsuccessful treatment outcomes (failure, default, and death).

Results

A total of 841 patients were registered between January-June 2007 of which 792 (94%) were cured. Independent risk factors for non-cure were having a low income (<3000 RMB per year), not having medical insurance, a delay in health care seeking >30 days, a positive smear test result two months after start of treatment, not being aware of the need to go to the CDC for medical follow up during treatment, and not seeing the need for treatment observation.

Conclusion

Reducing the financial burden of TB disease and providing health education to improve compliance with treatment could increase the proportion of patients with successful treatment outcomes.

Barriers to tuberculosis control and prevention in undergraduates in Xi'an, China: A qualitative study

To understand the barriers to tuberculosis (TB) control and prevention in undergraduate students and to propose the strategies to improve this work, we conducted in-depth interviews with three groups of individuals in infirmaries of universities and colleges, TB departments of district Centers for Disease Control and Prevention (CDCs), and undergraduates with TB. The study identified four major themes: inadequate workforce and less than optimal functioning of infirmaries and district TB control agencies; poor cooperation in the process of discovery, treatment, and surveillance of undergraduates with TB; poor acceptance of the national TB policy; and inadequate attention to TB prevention. Failure to carry out the national TB policy was the major barrier to TB control and prevention in undergraduates. TB control agencies should strengthen the implementation of the national TB policy.

Adherence to anti-tuberculosis treatment among pulmonary tuberculosis patients: a qualitative and quantitative study

BACKGROUND

Tuberculosis (TB) patients have difficulty following a long-term treatment regimen. Efforts to improve treatment outcomes require better understanding of adherence as a complex behavioral issue and of the particular barriers to and facilitators of patient adherence.

METHODS

This study was carried out in Jiangsu Province of China with both quantitative and qualitative approaches. For the quantitative study, 780 sputum-smear positive TB patients consecutively registered since 2006 in 13 counties (districts) were queried with a structured questionnaire. Patients who had missed 10% of their total prescribed doses of TB drugs were deemed as non-adherent. Risks for non-adherence were estimated by computing odds ratios (ORs) and their 95% confidence intervals (95% CIs) using a logistic regression model. We also invited 20 TB patients and 10 local health workers for in-depth interviews. We then used content analysis based on this qualitative study to explore factors associated with non-adherence.

RESULTS

The proportion of non-adherence among 670 patients was 12.2%. Univariate analysis showed that patients, who were illiterate, divorced/widowed, lacked health insurance and were migrants, were more likely to be non-adherent. The crude ORs(95%CIs) were 2.38(1.37-4.13), 2.42(1.30-4.52), 1.89(1.07-3.32) and 1.98(1.03-3.83), respectively. The risk of non-adherence was lower among patients whose treatment was given under direct observation by village doctors or regular home visits by health workers, with ORs (95% CIs) of 0.19(0.10-0.36) and 0.23(0.10-0.51), respectively. In multivariate analysis, factors associated with non-adherence included illiteracy (OR: 2.42; 95% CI: 1.25-4.67) and direct observation by village doctors (OR: 0.23; 95% CI: 0.11-0.45). The in-depth interviews indicated that financial burdens and extra medical expenditures, adverse drug reactions, and social stigma were additional potential factors accounted for non-adherence.

CONCLUSION

More importance should be given to treatment adherence under the current TB control program. Heavy financial burdens, lack of social support, adverse drug reactions and personal factors are associated with non-adherence. Direct observation and regular home visits by health workers appear to reduce the risk of non-adherence. More patient-centered interventions and greater attention to structural barriers are needed to improve treatment adherence.

Why financial incentives did not reach the poor tuberculosis patients? A qualitative study of a Fidelis funded project in Shanxi, China

BACKGROUND

A project implemented in 50 counties of Shanxi province provided incentives to poor TB patients for their first trip to tuberculosis (TB) dispensaries. Incentives were also given to doctors for referring and supervising TB patients. A previous quantitative evaluation identified no improvement on TB case detection and management. This qualitative study was then conducted to explore reasons for project failure.

OBJECTIVE

To understand how the incentives were distributed to and viewed by their recipients and the implications for TB and health systems.

METHODS

Qualitative in-depth interviews were conducted with 32 TB patients, 13 village doctors, 12 village leaders, 8 TB doctors and 8 TB programme managers.

RESULTS

The study revealed a lack of operational tools on how to evaluate patients' economic status and how to publicise the incentives. As a result, patients did not know the level of incentives in advance and regarded the amount as inadequate. Patients faced a huge financial burden and a long delay in treating TB, dwarfing the benefits of travel incentives. The referral and case supervision incentives were not implemented. Doctors did not receive any referral and supervision incentives in addition to those already existing.

CONCLUSIONS

Strategies to address health system and TB programme issues should be implemented before or alongside financial incentives. Operational details and tools for any intervention should be developed, field-tested and revised prior to wide-scale use.

Gender difference in knowledge of tuberculosis and associated health-care seeking behaviors: a cross-sectional study in a rural area of China

BACKGROUND

Tuberculosis (TB) detection under the national TB control program in China follows passive case-finding guidelines, which could be influenced by the accessibility of health service and patient's health-care seeking behaviors. One intriguing topic is the correlation between men and women's knowledge on TB and their health-care seeking behaviors.

METHODS

Two cross-sectional studies were separately carried out in Yangzhong County, a rural area of China. One study, by using systematic sampling method, including 1,200 subjects, was conducted to investigate the TB knowledge among general population. Another study in the same source population screened 33,549 people aged 15 years or over among 20 stratified cluster-sampled villages for identifying prolonged cough patients at households and individual interviews were then carried out. Gender difference in the knowledge of TB and health-care seeking behaviors was analyzed particularly.

RESULTS

Among general population, only 16.0% (men 17.1% vs. women 15.0%) knew the prolonged cough with the duration of 3 weeks or longer was a symptom for suspicious TB. Fewer women than men knew the local appointed health facility for TB diagnosis and treatment as well as the current free TB service policy. Moreover, women were less likely to learn information about TB and share it with others on their own initiatives. On the contrary, after the onset of the prolonged cough, women (79.2%) were more likely to seek health-care than men (58.6%) did. However, a large part of women preferred to visit the lower level non-hospital health facilities at first such as village clinics and drugstores.

CONCLUSION

TB and DOTS program were not well known by rural Chinese. Gender issues should be considered to reduce diagnostic delay of TB and improve both men and women's access to qualified health facility for TB care. Strengthening awareness of TB and improving the accessibility of health-care service is essential in TB control strategy, especially under the current vertical TB control system.