Tackling challenges of TB/MDRTB in China: concerted actions are imperative

Influence of Public Health Services on the Goal of Ending Tuberculosis: Evidence From Panel Data in China

Background

The World Health Organization has proposed an initiative to “end tuberculosis (TB).” Unfortunately, TB continues to endanger the health of people worldwide. We investigated the impact of public health services (PHS) in China on TB incidence. In this way, we provided policy ideas for preventing the TB epidemic.

Methods

We used the “New Public Management Theory” to develop two indicators to quantify policy documents: multisector participation (MP) and the Assessable Public Health Service Coverage Rate (ASCR). The panel data from 31 provinces in Chinese mainland were collected from 2005 to 2019 based on 1,129 policy documents and the China Statistical Yearbook. A fixed-effect model was used to determine the impact of MP and the ASCR on TB incidence.

Results

From 2005 to 2019, the average MP increased from 89.25 to 97.70%, and the average ASCR increased from 53.97 to 78.40% in Chinese mainland. However, the development of ASCR between regions was not balanced, and the average level in the western region was lower than that in the eastern coastal provinces. With an increase in MP and the ASCR, the TB incidence had been decreasing gradually in recent years. The panel analysis results showed that MP (β = −0.76, p < 0.05). and ASCR (β = −0.40, p < 0.01) had a negative effect on TB incidence, respectively. Even if the control variables were added, the negative effects of MP (β = −0.86, p < 0.05) and ASCR (β = −0.35, p < 0.01) were still statistically significant.

Conclusions

Promoting the participation of multiple departments, as well as emphasizing the quality of PHS delivery, are important ways to alleviate the TB epidemic. The settings of evaluation indices for PHS provision should be strengthened in the future.

Challenges Faced by Multidrug-Resistant Tuberculosis Patients in Three Financially Affluent Chinese Cities

Purpose

The aim of this study was to analyze socioeconomic burdens and other difficulties that multidrug-resistant tuberculosis (MDR-TB) patients in cities are facing, to identify major obstacles and which groups of patients are most affected.

Methods

Face-to-face and phone-call interviews were conducted in early 2018 to follow-up with patients newly diagnosed with MDR-TB in 2017 in three tuberculosis hospitals in three financially affluent Chinese cities. Demographic data and information on their medical care, insurance coverage, and medical expenses were collected and analyzed.

Results

A total of 144 newly diagnosed MDR-TB cases were reviewed during the study period, excluding 38 who were lost to follow-up and 29 patients who refused to participate, 77 patients were enrolled in this study. A total of 61 (79%) of these patients were hospitalized after MDR-TB diagnosis with an average hospital stay of 14 days, of them 57 (74%) were sputum positive on diagnosis. The proportion of patients who failed community care were 48% married, 56% in white collar employment and 43% in temp jobs/unemployed. In terms of insurance coverage, the proportion of patients who failed community care were 23% with no insurance and/or New Rural Co-operative Medical Care Scheme (NRCMS) and 45% with Urban Employee Basic Medical Insurance (UEBMI)/Urban Residents Basic Medical Insurance (URBMI) and commercial insurance. Difficulties patients encountered were, financial pressure (33%), psychological stress (26%), adverse drug reactions (23%), repulsive reaction to injections (17%). Fourty-eight percent of the patients spent over ¥2000 (USD300) per month on TB treatment.

Conclusion

Despite insurance coverage, financial hardship remains the number one difficulty MDR-TB patients encountered in relatively financially affluent cities. Among them, the married working class were found to be the most financially sensitive group and have the highest tendency to fail community care. It is of utmost urgency to enhance the current medical policy to improve treatment adherence.

Utilization and expenses of outpatient services among tuberculosis patients in three Chinese counties: an observational comparison study

Background

The China-Gates TB project Phase II implemented case-based payment reform in three Chinese counties in 2014, designed specifically for patients diagnosed with Tuberculosis (TB). This study aimed to examine the changes in utilization and expenses of outpatient services before and after the reform implementation, among TB patients in the three counties in China.

Methods

We collected quantitative data using surveys in 2013 (baseline year) and 2015 (final year). We used outpatient hospital records to measure service utilization and medical expenses of TB patients. We conducted qualitative interviews with local health authorities, officers of health insurance agencies, and hospital managers (n = 18). We utilized three focus group discussions with hospital staff and TB doctors and nurses. The χ² tests and Mann-Whitney U tests were used to analyse quantitative data, and the thematic analysis using a framework approach was applied to analyse qualitative data.

Results

Dantu and Yangzhong counties enacted TB-specific case-based payment method in 2014. Jurong County maintained global budget payment but raised the reimbursement rate for TB care. Compared to the baseline, the percentage of TB patients in Dantu and Yangzhong with eight or above outpatient visits increased from 7.5 to 55.1% and from 22.1 to 53.1% in the final survey, respectively. Jurong experienced the opposite trend, decreasing from 63.0 to 9.8%. In the final survey, the total outpatient expenses per patient during a full treatment course in Dantu (RMB 2939.7) and Yangzhong (RMB 2520.6) were significantly higher than those in the baseline (RMB 690.4 and RMB 1001.5, respectively), while the total outpatient expenses in Jurong decreased significantly (RMB 1976.0 in the baseline and RMB 660.8 in the final survey). Health insurance agencies in Dantu and Yangzhong did not approve the original design with outpatient and inpatient expenses packaged together, revealed by qualitative interviews. Furthermore, staff at designated hospitals misunderstood that health insurance agencies would only reimburse actual expenses. Many TB doctors complained about their reduced salary, which might be due to decreased hospital revenue generated from TB care after the payment method reform.

Conclusions

The intended effect on cost containment of case-based payment was not evident in Dantu and Yangzhong. In Jurong, where the global budget payment system maintained with the reimbursement rate enhanced, we found an effect on cost containment, but the quality of TB care might be compromised. The TB-specific case-based payment method could be redesigned to combine payment on outpatient and inpatient expenses and to set an appropriate payment standard for TB care during a full treatment course. Local health insurance agencies have to provide explicit explanations on the payment method. TB care providers should be provided with proper incentives. Monitoring and evluaiton on the quality of TB care should be undertaken at regular intervals.

Electronic supplementary material

The online version of this article (10.1186/s40249-019-0590-0) contains supplementary material, which is available to authorized users.

The impact of increased reimbursement rates under the new cooperative medical scheme on the financial burden of tuberculosis patients

Background

Tuberculosis (TB) is still a major public health problem in China. To scale up TB control, an innovative programme entitled the ‘China-Gates Foundation Collaboration on TB Control in China was initiated in 2009. During the second phase of the project, a policy of increased reimbursement rates under the New Cooperative Medical Scheme (NCMS) was implemented. In this paper, we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data.

Methods

In two cross-sectional surveys, quantitative data were collected before (January 2010 to December 2012) and after (April 2014 to June 2015) the intervention in the existing NCMS routine data system. Information on all 313 TB inpatients, among which 117 inpatients in the project was collected. Qualitative data collection included 11 focus group discussions. Three main indicators, non-reimbursable expenses rate (NER), effective reimbursement rate (ERR), and out-of-pocket payment (OOP) as a percentage of per capita household income, were used to measure the impact of intervention by comprising post-intervention data with baseline data. The quantitative data were analysed by descriptive analysis and non-parametric tests (Mann-Whitney U test) using SPSS 22.0, and qualitative data were subjected to thematic framework analysis using Nvivo10.

Results

The nominal reimbursement rates for inpatient care were no less than 80% for services within the package. Total inpatient expenses greatly increased, with an average growth rate of 11.3%. For all TB inpatients, the ERR for inpatient care increased from 52 to 66%. Compared with inpatients outside the project, for inpatients covered by the new policy, the ERR was higher (78%), and OOP showed a sharper decline. In addition, their financial burden decreased significantly.

Conclusions

Although the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy, inpatient OOP expenditure was still a major financial problem for patients. Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement. Comprehensive control models are needed to effectively decrease the financial burden on all TB patients.

Electronic supplementary material

The online version of this article (10.1186/s40249-019-0575-z) contains supplementary material, which is available to authorized users.

Impact of an innovative financing and payment model on tuberculosis patients' financial burden: is tuberculosis care more affordable for the poor?

BACKGROUND

In response to the high financial burden of health services facing tuberculosis (TB) patients in China, the China-Gates TB project, Phase II, has implemented a new financing and payment model as an important component of the overall project in three cities in eastern, central and western China. The model focuses on increasing the reimbursement rate for TB patients and reforming provider payment methods by replacing fee-for-service with a case-based payment approach. This study investigated changes in out-of-pocket (OOP) health expenditure and the financial burden on TB patients before and after the interventions, with a focus on potential differential impacts on patients from different income groups.

METHODS

Three sample counties in each of the three prefectures: Zhenjiang, Yichang and Hanzhong were chosen as study sites. TB patients who started and completed treatment before, and during the intervention period, were randomly sampled and surveyed at the baseline in 2013 and final evaluation in 2015 respectively. OOP health expenditure and percentage of patients incurring catastrophic health expenditure (CHE) were calculated for different income groups. OLS regression and logit regression were conducted to explore the intervention's impacts on patient OOP health expenditure and financial burden after adjusting for other covariates. Key-informant interviews and focus group discussions were conducted to understand the reasons for any observed changes.

RESULTS

Data from 738 (baseline) and 735 (evaluation) patients were available for analysis. Patient mean OOP health expenditure increased from RMB 3576 to RMB 5791, and the percentage of patients incurring CHE also increased after intervention. The percentage increase in OOP health expenditure and the likelihood of incurring CHE were significantly lower for patients from the highest income group as compared to the lowest. Qualitative findings indicated that increased use of health services not covered by the standard package of the model was likely to have caused the increase in financial burden.

CONCLUSIONS

The implementation of the new financing and payment model did not protect patients, especially those from the lowest income group, from financial difficulty, due partly to their increased use of health service. More financial resources should be mobilized to increase financial protection, particularly for poor patients, while cost containment strategies need to be developed and effectively implemented to improve the effective coverage of essential healthcare in China.

Multidrug-resistant tuberculosis in rural China: lack of public awareness, unaffordable costs and poor clinical management

China has the second highest global incidence and prevalence of multidrug-resistant tuberculosis (MDR-TB). We describe here the life experience of a rural Chinese farmer with complicated and aggressive TB. It is unclear if this patient contracted MDR-TB initially or developed MDR-TB during treatment because the initial laboratory results are dubious. The lack of public awareness of TB in rural China fuelled by a belief in toxicity of TB treatment, as mentioned by his brother, caused the patient to stop his TB treatment repeatedly long before completion. The cost of MDR-TB treatment in China is unaffordable for most Chinese, especially those in rural areas. He paid about ¥300 000 (almost US$50 000) for his TB treatment. He was discharged early twice for 'financial difficulties'. This case highlights excessive costs, lack of public awareness, poor patient education, inadequate follow-up, lack of coordination between clinical services and the importance of treatment adherence.

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.

Spatial transmission and meteorological determinants of tuberculosis incidence in Qinghai Province, China: a spatial clustering panel analysis

BACKGROUND

Tuberculosis (TB) is the notifiable infectious disease with the second highest incidence in the Qinghai province, a province with poor primary health care infrastructure. Understanding the spatial distribution of TB and related environmental factors is necessary for developing effective strategies to control and further eliminate TB.

METHODS

Our TB incidence data and meteorological data were extracted from the China Information System of Disease Control and Prevention and statistical yearbooks, respectively. We calculated the global and local Moran's I by using spatial autocorrelation analysis to detect the spatial clustering of TB incidence each year. A spatial panel data model was applied to examine the associations of meteorological factors with TB incidence after adjustment of spatial individual effects and spatial autocorrelation.

RESULTS

The Local Moran's I method detected 11 counties with a significantly high-high spatial clustering (average annual incidence: 294/100 000) and 17 counties with a significantly low-low spatial clustering (average annual incidence: 68/100 000) of TB annual incidence within the examined five-year period; the global Moran's I values ranged from 0.40 to 0.58 (all P-values < 0.05). The TB incidence was positively associated with the temperature, precipitation, and wind speed (all P-values < 0.05), which were confirmed by the spatial panel data model. Each 10 °C, 2 cm, and 1 m/s increase in temperature, precipitation, and wind speed associated with 9 % and 3 % decrements and a 7 % increment in the TB incidence, respectively.

CONCLUSIONS

High TB incidence areas were mainly concentrated in south-western Qinghai, while low TB incidence areas clustered in eastern and north-western Qinghai. Areas with low temperature and precipitation and with strong wind speeds tended to have higher TB incidences.

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.

Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China

Background

Health inequity is an important issue all around the world. The Chinese basic medical security system comprises three major insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS). Little research has been conducted to look into the disparity in payments among the health insurance schemes in China. In this study, we aimed to evaluate the disparity in reimbursements for tuberculosis (TB) care among the abovementioned health insurance schemes.

Methods

This study uses a World Health Organization (WHO) framework to analyze the disparities and equity relating to the three dimensions of health insurance: population coverage, the range of services covered, and the extent to which costs are covered. Each of the health insurance scheme’s policies were categorized and analyzed. An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city (YC), which included 1506 discharges, was conducted to identify the differences in reimbursement rates and out-of-pocket (OOP) expenses among the health insurance schemes.

Results

Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by (TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI, who have less inpatient expenses than those covered by the UEBMI). We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups. In terms of financial inequity, TB patients who earned less paid more. The NCMS provides modest financial protection, based on income. Overall, TB patients from lower socioeconomic groups were the most vulnerable.

Conclusion

There are large disparities in reimbursement for TB care among the three health insurance schemes and this, in turn, hampers TB control. Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control. Achieving equity through integrated policies that avoid discrimination is likely to be effective.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0102-4) contains supplementary material, which is available to authorized users.