Is equity being sacrificed? Willingness and ability to pay for schistosomiasis control in China

Economic and financial evaluation of neglected tropical diseases

Economic and financing studies are particularly important for decision-making when resources are scarce or considerably limited. This is the case for neglected tropical diseases (NTDs). In fact, the definition of NTDs is an economic one. The shortage of resources for NTD control may be due in large part to the fact that the burden of NTDs and economic value of control measures have not been fully characterized. A number of economic study methodologies are available: cost of illness can quantify the extent, magnitude, and change of a problem; cost of intervention studies can outline the feasibility and guide the design of a policy or intervention; and cost-benefit, cost-effectiveness, and return-on-investment studies can determine the potential value of different interventions and policies. NTDs have unique characteristics that require special consideration in such analyses. Hence, approaches used for other diseases may need modifications to capture the full impact of NTDs. While the existing literature has made important findings, there is a need for substantially more work, as many NTDs and their associated interventions and policies require more evaluation. With increasing work in this area, NTDs may not be as 'neglected' in the future as they are now.

Health access livelihood framework reveals potential barriers in the control of schistosomiasis in the Dongting Lake area of Hunan Province, China

Background

Access to health care is a major requirement in improving health and fostering socioeconomic development. In the People's Republic of China (P.R. China), considerable changes have occurred in the social, economic, and health systems with a shift from a centrally planned to a socialist market economy. This brought about great benefits and new challenges, particularly for vertical disease control programs, including schistosomiasis. We explored systemic barriers in access to equitable and effective control of schistosomiasis.

Methodology

Between August 2002 and February 2003, 66 interviews with staff from anti-schistosomiasis control stations and six focus group discussions with health personnel were conducted in the Dongting Lake area, Hunan Province. Additionally, 79 patients with advanced schistosomiasis japonica were interviewed. The health access livelihood framework was utilized to examine availability, accessibility, affordability, adequacy, and acceptability of schistosomiasis-related health care.

Principal Findings

We found sufficient availability of infrastructure and human resources at most control stations. Many patients with advanced schistosomiasis resided in non-endemic or moderately endemic areas, however, with poor accessibility to disease-specific knowledge and specialized health services. Moreover, none of the patients interviewed had any form of health insurance, resulting in high out-of-pocket expenditure or unaffordable care. Reports on the adequacy and acceptability of care were mixed.

Conclusions/Significance

There is a need to strengthen health awareness and schistosomiasis surveillance in post-transmission control settings, as well as to reduce diagnostic and treatment costs. Further studies are needed to gain a multi-layered, in-depth understanding of remaining barriers, so that the ultimate goal of schistosomiasis elimination in P.R. China can be reached.

China has made great strides toward reducing the burden of schistosomiasis, facilitated by sustained political commitment and a multi-faceted, integrated control strategy. The ultimate goal is disease elimination, which might be challenging due to high rates of re-infection, clusters of re-emergence, and growing health disparities. Market-oriented reforms and system-wide policies within the health care system offer new opportunities, but also entail challenges for the national schistosomiasis control program. Few studies have examined systemic barriers to equitable and effective schistosomiasis control in China. We explored the five core dimensions of access to health care, placing emphasis on schistosomiasis in the Dongting Lake area of Hunan Province. We collected and analyzed perspectives from staff working at local anti-schistosomiasis control stations and designated schistosomiasis hospitals, and from patients with advanced schistosomiasis. Our data suggest that a lack of affordability and high out-of-pocket expenditure posed a major barrier to the health care users, as did a lack of relevant health-information, and poorly accessible diagnostic and specialized surgical services. The lessons learned from this work are important in the design and development of disease control programs and entail key policy implications for schistosomiasis elimination.

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.

Large water management projects and schistosomiasis control, Dongting Lake region, China

Construction of the Three Gorges Dam across the Yangtze River will substantially change the ecology of the Dongting Lake in southern China. In addition, the Chinese Central and Hunan Provinces' governmental authorities have instigated a Return Land to Lake Program that will extend the Dongting Lake surface area from the current 2,681 km2 to 4,350 km2. The previous construction of embankments and the large silt deposits made by the Yangtze River and other connecting rivers have contributed to frequent disastrous flooding. As a consequence of the 2 water projects, > 2 million persons and their domestic animals are being resettled. This article provides an overview of the historical background of these 2 large water management projects, the associated population movement, and their impact on future transmission and control of schistosomiasis in the Dongting Lake area. The dam will likely substantially extend the range of the snail habitats and increase schistosome transmission and schistosomiasis cases.

Large water management projects and schistosomiasis control, Dongting Lake region, China

Construction of the Three Gorges Dam across the Yangtze River will substantially change the ecology of the Dongting Lake in southern China. In addition, the Chinese Central and Hunan Provinces' governmental authorities have instigated a Return Land to Lake Program that will extend the Dongting Lake surface area from the current 2,681 km2 to 4,350 km2. The previous construction of embankments and the large silt deposits made by the Yangtze River and other connecting rivers have contributed to frequent disastrous flooding. As a consequence of the 2 water projects, > 2 million persons and their domestic animals are being resettled. This article provides an overview of the historical background of these 2 large water management projects, the associated population movement, and their impact on future transmission and control of schistosomiasis in the Dongting Lake area. The dam will likely substantially extend the range of the snail habitats and increase schistosome transmission and schistosomiasis cases.

The social and economic context and determinants of schistosomiasis japonica

A variety of biological and social factors govern schistosomiasis japonica in China. Social factors include those at a national and regional level, such as policies and patterns of development, which impact on local economic activities, and affect community, household and personal risk factors of infection. Drawing on research conducted in China, we illustrate how social structural and related factors influence individual risk and prevalence of infection. At a macro-level, political changes have occurred resulting in the shift from collective to family-based production, leading to clustering of infection in families. Industrialization and urbanization, and associated increased population mobility, have also influenced patterns of transmission and infection. Types of activities and local production patterns determine the exposure of individuals to schistosome-infested water sources. Fishermen have the most frequent water contact, aquatic workers the second and farmers the third; the relative risk of Schistosoma japonicum infection follows the same order. Among farmers, human infection is significantly related to agricultural production in rice fields infested with the intermediate host snail, and to rates of the infection in livestock. Risk of S. japonicum infection is also influenced by the domestic environment, including both the location of the house in relation to snail-colonized water sources, access to safe water, and improved sanitation. Household wealth and income determine family ability to provide and maintain safe water and sanitation, while determining or interacting with other variables. At an individual level, sex, age, educational level and ethnicity are all associated with different patterns of water use and water contact behaviour thereby affecting infection rates. Schistosomiasis impairs the growth and nutrition of children and the physical work capacity of adults, and so affects economic development. Given this, we note the importance of further research and social and contextual aspects of schistosomiasis infection in order to develop and sustain sound control strategies.

Applications and outcomes of periodic epidemiological surveys for schistosomiasis and related economic evaluation in the People's Republic of China

The great success in schistosomiasis control in China is attributable to a range of factors. Periodic epidemiological surveys (PES) used for monitoring and adapting control interventions over time are an integral feature of the national schistosomiasis control programme. PES have enabled the dynamic trends of schistosomiasis epidemics to be closely pursued and have assisted in analysing subtle changes in endemicity. The results can be summarised mathematically allowing the variation in efficacy of control measures to be readily determined and enabling control strategies to be adjusted and updated. PES have been used in both cross-sectional and longitudinal pilot studies selected by appropriate sampling methods. In the early 1990s, when the World Bank Loan Project for schistosomiasis control commenced, economic evaluations were initiated in parallel. Cost-effectiveness analysis became a necessary tool to identify the most financially feasible yet effective options among a range of alternative control strategies. There was, however, a lack of standardised approaches rendering study comparisons across sites difficult. The global burden of disease study established the disability adjusted life year (DALY) as a measure of population health, combining in a single indicator years lost from premature death and years of life lived with disability. However, a recent meta-analysis reveals that the burden of schistosomiasis is underestimated, and hence, needs to be revised. It is envisaged that after the revision of DALYs lost due to schistosomiasis japonica, they will become an essential measure in future schistosomiasis control assessments in China and in other schistosome-endemic areas of the world.

Epidemiology and control of mekongi schistosomiasis

Since the first case of Schistosoma mekongi infection was reported in 1957, control measures have been implemented in Laos and in Cambodia. Operational research provided the necessary information on parasite epidemiology and the associated morbidity in order to develop adequate control measures. S. mekongi transmission occurs in rocky banks of the river according to a seasonal cycle. Common daily activities of villagers living in the endemic areas constitute the risk factors for infection. The potential role of an animal reservoir is not fully understood. Severe disease is associated with advanced infection status. Signs and symptoms of portal hypertension dominate the clinical situation, and death is usually due to bleeding from ruptured esophageal varices. Schistosomiasis control in both Laos and Cambodia was based on universal treatment campaigns and resulted in a dramatic fall in the prevalence of the infection and in morbidity control. However, even if the disease and the infection have been satisfactorily controlled, transmission still occurs, and in very limited areas the prevalence reaches rates of more than 15%. Today, 60000 people are estimated to be still at risk of infection in Laos and about 80,000 in Cambodia. The new challenge in schistosomiasis control in endemic areas along the Mekong river is to consolidate the results, to establish a sensitive and reliable surveillance system, and finally to adapt control strategies to the low endemic situation. The impoverished nature of the region makes the possibility of sanitation unfeasible, and external support is still needed to sustain activities in the near future and to enable the substantial reduction of risk behaviors.