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Chatterjee S, Das P, Stallworthy G, Bhambure G, Munje R, Vassall A. Catastrophic costs for tuberculosis patients in India: Impact of methodological choices. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003078. [PMID: 38669225 PMCID: PMC11051603 DOI: 10.1371/journal.pgph.0003078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/16/2024] [Indexed: 04/28/2024]
Abstract
As financial risk protection is one of the goals towards universal health coverage, detailed information on costs, catastrophic costs and other economic consequences related to any disease are required for designing social protection measures. End Tuberculosis (TB) Strategy set a milestone of achieving zero catastrophic cost by 2020. However, a recent literature review noted that 7%-32% TB affected households in India faced catastrophic cost. Studies included in the review were small scale cross-sectional. We followed a cohort of 1482 notified drug-susceptible TB patients from four states in India: Assam, Maharashtra, Tamil Nadu, and West Bengal to provide a comprehensive picture of economic burden associated with TB treatment. Treatment cost was calculated using World Health Organization guidelines on TB patient cost survey and both human capital and output approaches of indirect cost (time, productivity, and income loss related to an episode) calculation were used to provide the range of households currently facing catastrophic cost. Depending on choice of indirect cost calculation method, 30%-61% study participants faced catastrophic cost. For over half of them, costs became catastrophic even before starting TB treatment as there was average 7-9 weeks delay from symptom onset to treatment initiation which was double the generally accepted delay of 4 weeks. During that period, they made average 8-11 visits to different providers and spent money on consultations, drugs, tests, and travel. Following the largest cohort of drug-susceptible TB patients till date, the study concluded that a significant proportion of study participants faced catastrophic cost and the proportion was much higher when income loss was considered as indirect cost calculation method. Therefore, ensuring uninterrupted livelihood during TB treatment is an absolute necessity. Another reason of high cost was the delay in diagnosis and costs incurred during pre-diagnosis period. This delay and consequently, economic burden, can be reduced by both supply side (intense private sector engagement, rapid diagnosis) and demand side (community engagement) initiatives. Reimbursement of expenses incurred before treatment initiation could be used as short-term measure for mitigating financial hardship.
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Affiliation(s)
- Susmita Chatterjee
- Research Department, George Institute for Global Health, New Delhi, India
- Department of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Palash Das
- Research Department, George Institute for Global Health, New Delhi, India
| | - Guy Stallworthy
- Bill & Melinda Gates Foundation, Global Health Division, Seattle, Washington State, United States of America
| | - Gayatri Bhambure
- Research Department, George Institute for Global Health, New Delhi, India
| | - Radha Munje
- Department of Respiratory Medicine, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Cruz Martínez OA, García I, Puerto GM, Alvis-Zakzuk NJ, López MP, Moreno Cubides JC, Sánchez Salazar ÁM, Trujillo Trujillo J, Castro-Osorio CM, Vanessa Rubio V, Castañeda-Orjuela C, Montoro E, Nguhiu P, García Baena I. Tuberculosis patients face high treatment support costs in Colombia, 2021. PLoS One 2024; 19:e0296250. [PMID: 38635755 PMCID: PMC11025946 DOI: 10.1371/journal.pone.0296250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/09/2023] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVE To estimate the baseline to measure one of the three indicators of the World Health Organization (WHO) End TB strategy (2015-2035), measure the costs incurred by patients affected by tuberculosis (TB) during a treatment episode and estimate the proportion of households facing catastrophic costs (CC) and associated risk factors, in Colombia, 2021. MATERIAL AND METHODS A nationally representative cross-sectional survey was conducted among participants on TB treatment in Colombia, using telephone interviews due to the exceptional context of the COVID-19 pandemic. The survey collected household costs (direct [medical and non-medical out-of-pocket expenses] and indirect) over an episode of TB, loss of time, coping measures, self-reported income, and asset ownership. Total costs were expressed as a proportion of annual household income and analyzed for risk factors of CC (defined as costs above 20% annual household income). RESULTS The proportion of TB-affected households incurring in costs above 20% annual household income (CC) was 51.7% (95%CI: 45.4-58.0) overall, 51.3% (95%CI: 44.9-57.7) among patients with drug-sensitive (DS) TB, and 65.0% (95%CI: 48.0-82.0) among drug-resistant (DR). The average patient cost of a TB case in Colombia was $1,218 (95%CI 1,106-1,330) including $860.9 (95%CI 776.1-945.7) for non-medical costs, $339 (95%CI 257-421) for the indirect costs, and $18.1 (95%CI 11.9-24.4) for the medical costs. The factors that influenced the probability of facing CC were income quintile, job loss, DR-TB patient, and TB type. CONCLUSION Main cost drivers for CC were non-medical out-of-pocket expenses and income loss (indirect costs). Current social protection programs ought to be expanded to mitigate the proportion of TB-affected households facing CC in Colombia, especially those with lower income levels.
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Affiliation(s)
- Oscar Andrés Cruz Martínez
- Programa Nacional para el Control de la Tuberculosis, Ministerio de Salud y Protección Social, Bogotá, D.C., Colombia
| | - Ingrid García
- Área Prevención y Control de Enfermedades CDE, Organización Panamericana de la Salud/Organización Mundial de la Salud, Bogotá, D.C., Colombia
| | - Gloria Mercedes Puerto
- Instituto Nacional de Salud, Red Nacional de Investigación, Innovación y Gestión del Conocimiento de TB en Colombia, Grupo de Micobacterias, Dirección de Investigación en Salud Pública, Bogotá, D.C., Colombia
| | - Nelson J. Alvis-Zakzuk
- Global TB Programme, World Health Organization, Geneva, Switzerland
- Department of Health Sciences, Universidad de la Costa, Barranquilla, Colombia
- Laboratory of Causal Inference in Epidemiology (LINCE-USP), School of Public Health, Postgraduate Program in Epidemiology, University of São Paulo, São Paulo, Brazil
| | - Martha Patricia López
- Área Prevención y Control de Enfermedades CDE, Organización Panamericana de la Salud/Organización Mundial de la Salud, Bogotá, D.C., Colombia
| | - Juan Carlos Moreno Cubides
- Área Prevención y Control de Enfermedades CDE, Organización Panamericana de la Salud/Organización Mundial de la Salud, Bogotá, D.C., Colombia
| | | | - Julián Trujillo Trujillo
- Grupo Emergentes Reemergentes y Desatendidas, Ministerio de Salud y Protección Social, Bogotá, D.C., Colombia
- Universidad Nacional Abierta y a Distancia UNAD, Bogotá, D.C., Colombia
| | - Claudia Marcela Castro-Osorio
- Instituto Nacional de Salud, Red Nacional de Investigación, Innovación y Gestión del Conocimiento de TB en Colombia, Grupo de Micobacterias, Dirección de Investigación en Salud Pública, Bogotá, D.C., Colombia
| | - Vivian Vanessa Rubio
- Instituto Nacional de Salud, Red Nacional de Investigación, Innovación y Gestión del Conocimiento de TB en Colombia, Grupo de Micobacterias, Dirección de Investigación en Salud Pública, Bogotá, D.C., Colombia
| | | | - Ernesto Montoro
- Departamento CDE, Unidad de VIH, Hepatitis, Tuberculosis e ITS, Organización Panamericana de la Salud/Organización Mundial, Washington, DC, Estados Unidos de América
| | - Peter Nguhiu
- Global TB Programme, World Health Organization, Geneva, Switzerland
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Forse R, Yoshino CA, Nguyen TT, Phan THY, Vo LNQ, Codlin AJ, Nguyen L, Hoang C, Basu L, Pham M, Nguyen HB, Van Dinh L, Caws M, Wingfield T, Lönnroth K, Sidney-Annerstedt K. Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance. Health Res Policy Syst 2024; 22:40. [PMID: 38566224 PMCID: PMC10985876 DOI: 10.1186/s12961-024-01132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Vietnam's primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process. METHODS A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated. RESULTS We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers. CONCLUSIONS Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.
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Affiliation(s)
- Rachel Forse
- Friends for International TB Relief, Hanoi, Vietnam.
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Clara Akie Yoshino
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Luan N Q Vo
- Friends for International TB Relief, Hanoi, Vietnam
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Andrew J Codlin
- Friends for International TB Relief, Hanoi, Vietnam
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | | | | | - Maxine Caws
- Centre for TB Research, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Tom Wingfield
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for TB Research, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kristi Sidney-Annerstedt
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
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Nguyen HB, Vo LNQ, Forse RJ, Wiemers AMC, Huynh HB, Dong TTT, Phan YTH, Creswell J, Dang TMH, Nguyen LH, Shedrawy J, Lönnroth K, Nguyen TD, Dinh LV, Annerstedt KS, Codlin AJ. Is convenience really king? Comparative evaluation of catastrophic costs due to tuberculosis in the public and private healthcare sectors of Viet Nam: a longitudinal patient cost study. Infect Dis Poverty 2024; 13:27. [PMID: 38528604 DOI: 10.1186/s40249-024-01196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/11/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND In Viet Nam, tuberculosis (TB) represents a devastating life-event with an exorbitant price tag, partly due to lost income from daily directly observed therapy in public sector care. Thus, persons with TB may seek care in the private sector for its flexibility, convenience, and privacy. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector. METHODS Between October 2020 and March 2022, we conducted 110 longitudinal patient cost interviews, among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program (NTP) in Ha Noi, Hai Phong and Ho Chi Minh City, Viet Nam. Using a local adaptation of the WHO TB patient cost survey tool, participants were interviewed during the intensive phase, continuation phase and post-treatment. We compared income levels, direct and indirect treatment costs, catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression. RESULTS The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort (USD 868 vs USD 578; P = 0.010). However, private sector treatment was also significantly costlier (USD 2075 vs USD 1313; P = 0.005), driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants (USD 754 vs USD 164; P < 0.001). This resulted in no significant difference in catastrophic costs between the two cohorts (Private: 55% vs NTP: 52%; P = 0.675). Factors associated with catastrophic cost included being a single-person household [adjusted odds ratio (aOR = 13.71; 95% confidence interval (CI): 1.36-138.14; P = 0.026], unemployment during treatment (aOR = 10.86; 95% CI: 2.64-44.60; P < 0.001) and experiencing TB-related stigma (aOR = 37.90; 95% CI: 1.72-831.73; P = 0.021). CONCLUSIONS Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector. Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector, use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.
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Affiliation(s)
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Ha Noi, Viet Nam.
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Huy Ba Huynh
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | | | | | | | | | - Jad Shedrawy
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | | | - Kristi Sidney Annerstedt
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Andrew James Codlin
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
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Yamanaka T, Castro MC, Ferrer JP, Cox SE, Laurence YV, Vassall A. Comparing disease specific catastrophic cost estimates using longitudinal and cross-sectional designs: The example of tuberculosis. Soc Sci Med 2024; 344:116631. [PMID: 38308959 DOI: 10.1016/j.socscimed.2024.116631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND There has been an increasing interest in assessing disease-specific catastrophic costs incurred by affected households as part of economic evaluations and to inform joint social/health policies for vulnerable groups. Although the longitudinal study design is the gold standard for estimating disease-specific household costs, many assessments are implemented with a cross-sectional design for pragmatic reasons. We aimed at identifying the potential biases of a cross-sectional design for estimating household cost, using the example of tuberculosis (TB), and exploring optimal approaches for sampling and interpolating cross-sectional cost data to estimate household costs. METHODS Data on patient incurred costs, household income and coping strategies were collected from TB patients in Negros Occidental and Cebu in the Philippines between November 2018 and October 2020. The data collection tools were developed by adapting WHO Tuberculosis Patient Cost Surveys: A Handbook into a longitudinal study design. TB-specific catastrophic cost estimates were compared between longitudinal and simulated cross-sectional designs using different random samples from different times points in treatment (intensive and continuation phases). RESULTS A total of 530 adult TB patients were enrolled upon TB diagnosis in this study. Using the longitudinal design, the catastrophic cost estimate for TB-affected households was 69 % using the output approach. The catastrophic cost estimates with the simulated cross-sectional design were affected by the reduction and recovery in household income during the episode of TB care and ranged from 40 to 55 %. CONCLUSION Using longitudinally collected costs incurred by TB-affected households, we illustrated the potential limitations and implications of estimating household costs using a cross-sectional design. Not capturing changes in household income at multiple time points during the episode of the disease and estimating from inappropriate samples may result in biases that underestimates catastrophic cost.
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Affiliation(s)
- Takuya Yamanaka
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
| | | | | | - Sharon E Cox
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Institute of Tropical Medicine, Nagasaki University (NEKKEN), Nagasaki, Japan; UK Health Security Agency, London, UK
| | - Yoko V Laurence
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK; Health Economics for Life Sciences and Medicine, Department of Population Health Sciences, King's College London, London, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Akalu TY, Clements ACA, Wolde HF, Alene KA. Economic burden of multidrug-resistant tuberculosis on patients and households: a global systematic review and meta-analysis. Sci Rep 2023; 13:22361. [PMID: 38102144 PMCID: PMC10724290 DOI: 10.1038/s41598-023-47094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is a major health threat worldwide, causing a significant economic burden to patients and their families. Due to the longer duration of treatment and expensive second-line medicine, the economic burden of MDR-TB is assumed to be higher than drug-susceptible TB. However, the costs associated with MDR-TB are yet to be comprehensively quantified. We conducted this systematic review and meta-analysis to determine the global burden of catastrophic costs associated with MDR-TB on patients and their households. We systematically searched five databases (CINHAL, MEDLINE, Embase, Scopus, and Web of Science) from inception to 2 September 2022 for studies reporting catastrophic costs on patients and affected families of MDR-TB. The primary outcome of our study was the proportion of patients and households with catastrophic costs. Costs were considered catastrophic when a patient spends 20% or more of their annual household income on their MDR-TB diagnosis and care. The pooled proportion of catastrophic cost was determined using a random-effects meta-analysis. Publication bias was assessed using visualization of the funnel plots and the Egger regression test. Heterogeneity was assessed using I2, and sub-group analysis was conducted using study covariates as stratification variables. Finally, we used the Preferred Reporting Items for Reporting Systematic Review and Meta-Analysis-20 (PRISMA-20). The research protocol was registered in PROSPERO (CRD42021250909). Our search identified 6635 studies, of which 11 were included after the screening. MDR-TB patients incurred total costs ranging from $USD 650 to $USD 8266 during treatment. The mean direct cost and indirect cost incurred by MDR-TB patients were $USD 1936.25 (SD ± $USD 1897.03) and $USD 1200.35 (SD ± $USD 489.76), respectively. The overall burden of catastrophic cost among MDR-TB patients and households was 81.58% (95% Confidence Interval (CI) 74.13-89.04%). The catastrophic costs incurred by MDR-TB patients were significantly higher than previously reported for DS-TB patients. MDR-TB patients incurred more expenditure for direct costs than indirect costs. Social protection and financial support for patients and affected families are needed to mitigate the catastrophic economic consequences of MDR-TB.
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Affiliation(s)
- Temesgen Yihunie Akalu
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia.
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Archie C A Clements
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Haileab Fekadu Wolde
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kefyalew Addis Alene
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
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Noia Maciel EL, Negri LDSA, Guidoni LM, Fregona GC, Johansen FDC, Sanchez MN, Moreira ADSR, Diaz-Quijano FA, Tonini M, Zandonade E, Ershova J, Nguhiu P, Baena IG. The economic burden of households affected by tuberculosis in Brazil: First national survey results, 2019-2021. PLoS One 2023; 18:e0287961. [PMID: 38091306 PMCID: PMC10718450 DOI: 10.1371/journal.pone.0287961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 06/19/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND One of the three main targets of the World Health Organization (WHO) End TB Strategy (2015-2035) is that no tuberculosis (TB) patients or their households face catastrophic costs (defined as exceeding 20% of the annual household income) because of the disease. Our study seeks to determine, as a baseline, the magnitude and main drivers of the costs associated with TB disease for patients and their households and to monitor the proportion of households experiencing catastrophic costs in Brazil. METHODS A national cross-sectional cluster-based survey was conducted in Brazil in 2019-2021 following WHO methodology. TB patients of all ages and types of TB were eligible for the survey. Adult TB patients and guardians of minors (<18 years old) were interviewed once about costs, time loss, coping measures, income, household expenses, and asset ownership. Total costs, including indirect costs measured as reported household income change, were expressed as a percentage of annual household income. We used descriptive statistics to analyze the cost drivers and multivariate logistic regression to determine factors associated with catastrophic costs. RESULTS We interviewed 603 patients, including 538 (89%) with drug-sensitive (DS) and 65 (11%) with drug-resistant (DR) TB. Of 603 affected households, 48.1% (95%CI: 43-53.2) experienced costs above 20% of their annual household income during their TB episode. The proportion was 44.4% and 78.5% among patients with DS- and DR-TB, respectively. On average, patients incurred costs of US$1573 (95%CI: 1361.8-1785.0) per TB episode, including pre-diagnosis and post-diagnosis expenses. Key cost drivers were post-diagnosis nutritional supplements (US$317.6, 95%CI: 232.7-402.6) followed by medical costs (US$85.5, 95%CI: 54.3-116.5) and costs of travel for clinic visits during treatment (US$79.2, 95%CI: 61.9-96.5). In multivariate analysis, predictors of catastrophic costs included positive HIV status (aOR = 3.0, 95%CI:1.1-8.6) and self-employment (aOR = 2.7, 95%CI:1.1-6.5); high education was a protective factor (aOR = 0.1, 95%CI:0.0-0.9). CONCLUSIONS Although the services offered to patients with TB are free of charge in the Brazilian public health sector, the availability of free diagnosis and treatment services does not alleviate patients' financial burden related to accessing TB care. The study allowed us to identify the costs incurred by patients and suggest actions to mitigate their suffering. In addition, this study established a baseline for monitoring catastrophic costs and fostering a national policy to reduce the costs to patients for TB care in Brazil.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Maiko Tonini
- University of Brasília, UNB, Brasília, DF, Brazil
| | | | - Julia Ershova
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Peter Nguhiu
- KEMRI- Wellcome Trust Research Program, Health Economics Research Unit, Nairobi, Kenya
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8
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Forse R, Nguyen TT, Dam T, Vo LNQ, Codlin AJ, Caws M, Minh HDT, Nguyen LH, Nguyen HB, Nguyen NV, Lönnroth K, Annerstedt KS. A qualitative assessment on the acceptability of providing cash transfers and social health insurance for tuberculosis-affected families in Ho Chi Minh City, Vietnam. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002439. [PMID: 38055709 DOI: 10.1371/journal.pgph.0002439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 09/09/2023] [Indexed: 12/08/2023]
Abstract
To achieve the Sustainable Development Goal's targets of universal health coverage (UHC) and poverty reduction, interventions are required that strengthen and harmonize both UHC and social protection. Vietnam is committed to achieving financial protection and over 90% of the general population has enrolled in its social health insurance (SHI) scheme. However, an estimated 63% of tuberculosis (TB)-affected households in Vietnam still face catastrophic costs and little is known about the optimal strategies to mitigate the costs of TB care for vulnerable families. This study assessed the acceptability of a social protection package containing cash transfers and SHI using individual interviews (n = 19) and focus group discussions (n = 3 groups). Interviews were analyzed through framework analysis. The study's main finding indicated that both conditional and unconditional cash transfers paired with SHI were acceptable, across six dimensions of acceptability. Cash transfers were considered beneficial for mitigating out-of-pocket expenditure, increasing TB treatment adherence, and improving mental health and general well-being, but the value provided was inadequate to fully alleviate the economic burden of the illness. The conditionality of the cash transfers was not viewed by participants as inappropriate, but it increased the workload of the TB program, which brought into question the feasibility of scale-up. SHI was viewed as a necessity by almost all participants, but people with TB questioned the quality of care received when utilizing it for auxiliary TB services. Access to multiple sources of social protection was deemed necessary to fully offset the costs of TB care. Additional research is needed to assess the impact of cash transfer interventions on health and economic outcomes in order to create an enabling policy environment for scale-up.
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Affiliation(s)
- Rachel Forse
- Friends for International TB Relief, Hanoi, Vietnam
- Department of Global Public Health, Karolinska Institutet, WHO Collaboration Centre on Tuberculosis and Social Medicine, Stockholm, Sweden
| | | | - Thu Dam
- Friends for International TB Relief, Hanoi, Vietnam
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Hanoi, Vietnam
- Department of Global Public Health, Karolinska Institutet, WHO Collaboration Centre on Tuberculosis and Social Medicine, Stockholm, Sweden
| | - Andrew James Codlin
- Friends for International TB Relief, Hanoi, Vietnam
- Department of Global Public Health, Karolinska Institutet, WHO Collaboration Centre on Tuberculosis and Social Medicine, Stockholm, Sweden
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | | | - Hoa Binh Nguyen
- National Lung Hospital/National TB Control Programme, Hanoi, Vietnam
| | - Nhung Viet Nguyen
- National Lung Hospital/National TB Control Programme, Hanoi, Vietnam
- University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, WHO Collaboration Centre on Tuberculosis and Social Medicine, Stockholm, Sweden
| | - Kristi Sidney Annerstedt
- Department of Global Public Health, Karolinska Institutet, WHO Collaboration Centre on Tuberculosis and Social Medicine, Stockholm, Sweden
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Pham TAM, Forse R, Codlin AJ, Phan THY, Nguyen TT, Nguyen N, Vo LNQ, Dat PT, Minh HDT, Nguyen LH, Nguyen HB, Nguyen NV, Bodfish M, Lönnroth K, Wingfield T, Annerstedt KS. Determinants of catastrophic costs among households affected by multi-drug resistant tuberculosis in Ho Chi Minh City, Viet Nam: a prospective cohort study. BMC Public Health 2023; 23:2372. [PMID: 38042797 PMCID: PMC10693707 DOI: 10.1186/s12889-023-17078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 10/26/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Globally, most people with multidrug-resistant tuberculosis (MDR-TB) and their households experience catastrophic costs of illness, diagnosis, and care. However, the factors associated with experiencing catastrophic costs are poorly understood. This study aimed to identify risk factors associated with catastrophic costs incurrence among MDR-TB-affected households in Ho Chi Minh City (HCMC), Viet Nam. METHODS Between October 2020 and April 2022, data were collected using a locally-adapted, longitudinal WHO TB Patient Cost Survey in ten districts of HCMC. Ninety-four people with MDR-TB being treated with a nine-month TB regimen were surveyed at three time points: after two weeks of treatment initiation, completion of the intensive phase and the end of the treatment (approximately five and 10 months post-treatment initiation respectively). The catastrophic costs threshold was defined as total TB-related costs exceeding 20% of annual pre-TB household income. Logistic regression was used to identify variables associated with experiencing catastrophic costs. A sensitivity analysis examined the prevalence of catastrophic costs using alternative thresholds and cost estimation approaches. RESULTS Most participants (81/93 [87%]) experienced catastrophic costs despite the majority 86/93 (93%) receiving economic support through existing social protection schemes. Among participant households experiencing and not experiencing catastrophic costs, median household income was similar before MDR-TB treatment. However, by the end of MDR-TB treatment, median household income was lower (258 [IQR: 0-516] USD vs. 656 [IQR: 462-989] USD; p = 0.003), and median income loss was higher (2838 [IQR: 1548-5418] USD vs. 301 [IQR: 0-824] USD; p < 0.001) amongst the participant households who experienced catastrophic costs. Being the household's primary income earner before MDR-TB treatment (aOR = 11.2 [95% CI: 1.6-80.5]), having a lower educational level (aOR = 22.3 [95% CI: 1.5-344.1]) and becoming unemployed at the beginning of MDR-TB treatment (aOR = 35.6 [95% CI: 2.7-470.3]) were associated with experiencing catastrophic costs. CONCLUSION Despite good social protection coverage, most people with MDR-TB in HCMC experienced catastrophic costs. Incurrence of catastrophic costs was independently associated with being the household's primary income earner or being unemployed. Revision and expansion of strategies to mitigate TB-related catastrophic costs, in particular avoiding unemployment and income loss, are urgently required.
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Affiliation(s)
- Thi Anh Mai Pham
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Rachel Forse
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden.
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam.
| | - Andrew J Codlin
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Thi Hoang Yen Phan
- Centre for Development of Community Health Initiatives, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Thanh Thi Nguyen
- Centre for Development of Community Health Initiatives, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Nga Nguyen
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Luan Nguyen Quang Vo
- Centre for Development of Community Health Initiatives, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Phan Thuong Dat
- Pham Ngoc Thach Hospital, 120 Hong Bang, Ward12, District 5, Ho Chi Minh City, Viet Nam
| | - Ha Dang Thi Minh
- Pham Ngoc Thach Hospital, 120 Hong Bang, Ward12, District 5, Ho Chi Minh City, Viet Nam
| | - Lan Huu Nguyen
- Pham Ngoc Thach Hospital, 120 Hong Bang, Ward12, District 5, Ho Chi Minh City, Viet Nam
| | - Hoa Binh Nguyen
- National Lung Hospital/National TB Control Programme, 463 Hoang Hoa Tham, Vinh Phu, Ba Dinh, Ha Noi, Viet Nam
| | - Nhung Viet Nguyen
- National Lung Hospital/National TB Control Programme, 463 Hoang Hoa Tham, Vinh Phu, Ba Dinh, Ha Noi, Viet Nam
- University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | - Miranda Bodfish
- CDC Foundation, 600 Peachtree Street NE, Suite 1000, Atlanta, USA
| | - Knut Lönnroth
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Tom Wingfield
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
- Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, Merseyside, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, L7 8XP, Merseyside, UK
| | - Kristi Sidney Annerstedt
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
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Bengey D, Thapa A, Dixit K, Dhital R, Rai B, Paudel P, Paudel R, Majhi G, Aryal TP, Sah MK, Pandit RN, Mishra G, Khanal MN, Kibuchi E, Caws M, de Siqueira-Filha NT. Comparing cross-sectional and longitudinal approaches to tuberculosis patient cost surveys using Nepalese data. Health Policy Plan 2023; 38:830-839. [PMID: 37300553 PMCID: PMC10394499 DOI: 10.1093/heapol/czad037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023] Open
Abstract
The World Health Organization has supported the development of national tuberculosis (TB) patient cost surveys to quantify the socio-economic impact of TB in high-burden countries. However, methodological differences in the study design (e.g. cross-sectional vs longitudinal) can generate different estimates making the design and impact evaluation of socio-economic protection strategies difficult. The objective of the study was to compare the socio-economic impacts of TB estimated by applying cross-sectional or longitudinal data collections in Nepal. We analysed the data from a longitudinal costing survey (patients interviewed at three time points) conducted between April 2018 and October 2019. We calculated both mean and median costs from patients interviewed during the intensive (cross-sectional 1) and continuation (cross-sectional 2) phases of treatment. We then compared costs, the prevalence of catastrophic costs and the socio-economic impact of TB generated by each approach. There were significant differences in the costs and social impacts calculated by each approach. The median total cost (intensive plus continuation phases) was significantly higher for the longitudinal compared with cross-sectional 2 (US$119.42 vs 91.63, P < 0.001). The prevalence of food insecurity, social exclusion and patients feeling poorer or much poorer were all significantly higher by applying a longitudinal approach. In conclusion, the longitudinal design captured important aspects of costs and socio-economic impacts, which were missed by applying a cross-sectional approach. If a cross-sectional approach is applied due to resource constraints, our data suggest that the start of the continuation phase is the optimal timing for a single interview. Further research to optimize methodologies to report patient-incurred expenditure during TB diagnosis and treatment is needed.
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Affiliation(s)
- Daisy Bengey
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
| | - Anchal Thapa
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Kritika Dixit
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
- Department of Global Public Health, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Raghu Dhital
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Bhola Rai
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Puskar Paudel
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Rajan Paudel
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Govind Majhi
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | | | - Manoj Kumar Sah
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | | | - Gokul Mishra
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Mukti Nath Khanal
- Planning Monitoring Evaluation & Research Section, National Tuberculosis Control Center, Thimi, Bhaktapur, Nepal
| | - Eliud Kibuchi
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, 90 Byres Road, Glasgow G12 8TB, United Kingdom
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
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11
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Abdulla JH, Gebremichael B, Maruta MB, Yuye I, Mohammed A, Debella A, Mussa I. Nearly one out of every five adult TB patients suffered from food insecurity in Grawa District, Eastern Ethiopia: a multicenter facility-based cross-sectional study. Front Public Health 2023; 11:1177618. [PMID: 37361149 PMCID: PMC10288987 DOI: 10.3389/fpubh.2023.1177618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023] Open
Abstract
Background Despite a dramatic decline in tuberculosis mortality over the past 10 years, tuberculosis is still the leading cause of death globally. In the last 2 years, tuberculosis has affected an estimated 10 million individuals, and 1.4 million people have died worldwide. In Ethiopia, the weight of the problem is less known in the study area. As a result, the purpose of this study was to assess food insecurity and associated factors among adult patients with tuberculosis attending public health facilities in Grawa district, Eastern Ethiopia. Methods A multicenter facility-based cross-sectional study was conducted from 01 March to 31 March 2022, among 488 randomly selected adult tuberculosis patients on treatment follow-up at public health facilities in Grawa district, Eastern Ethiopia. Data were collected using a pretested structured questionnaire through a face-to-face interview and document review, entered into EpiData version 3.1, and analyzed using SPSS version 25. The prevalence was reported using a 95% confidence interval (CI) and summary measures. Predictors were assessed using a multivariable logistic regression analysis model and reported using an adjusted odds ratio (AOR) with 95% CI. Statistical significance was declared at a p-value of <0.05. Results Overall, the prevalence of food insecurity among the study participants was 19.5%, with a 95% CI (15.8%, 23.2%). Factors such as being male [AOR = 0.58, 95% CI: (0.34, 0.97)], being married [AOR = 2.93, 95% CI: (1.33, 6.47)], being merchant [AOR = 0.22, 95% CI: (0.04, 0.67)], having low wealth quintiles [AOR = 2.10,95%CI:(1.04-4.23)], receiving anti-TB treatment for two or fewer months [AOR = 0.48, 95% CI: (0.26-0.91)], using khat [AOR = 2.18, 95% CI: (1.29, 3.70)], and owning livestock (AOR = 0.56, 95% CI: 0.29-0.94) were significantly associated with food insecurity. Conclusions According to this study, nearly one out of every five adults TB patients is food insecure. Factors such as being male, being married, being merchant, having low wealth quintiles, receiving anti-TB treatment for two or less months, those who chew mKhat and having a livestock were significantly associated with food insecurity. As a result, all stakeholders and concerned entities should prioritize improving the livelihood of TB patients through social security system programs, which are critical to the success of TB control and prevention efforts.
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Affiliation(s)
- Jabir H. Abdulla
- Department of Family Health, Grawa Health Bureau, Grawa, Ethiopia
| | - Berhe Gebremichael
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Melat B. Maruta
- School of Medicine, Obstetrics and Gynecology, Menelik Hospital, Addis Ababa, Ethiopia
| | - Ibsa Yuye
- Resource Mobilization and Health Financing, East Hararghe Zonal Health Office, Harar, Ethiopia
| | | | - Adera Debella
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Ibsa Mussa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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12
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Quang Vo LN, Forse RJ, Tran J, Dam T, Driscoll J, Codlin AJ, Creswell J, Sidney-Annerstedt K, Van Truong V, Thi Minh HD, Huu LN, Nguyen HB, Nguyen NV. Economic evaluation of a community health worker model for tuberculosis care in Ho Chi Minh City, Viet Nam: a mixed-methods Social Return on Investment Analysis. BMC Public Health 2023; 23:945. [PMID: 37231468 DOI: 10.1186/s12889-023-15841-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND There is extensive evidence for the cost-effectiveness of programmatic and additional tuberculosis (TB) interventions, but no studies have employed the social return on investment (SROI) methodology. We conducted a SROI analysis to measure the benefits of a community health worker (CHW) model for active TB case finding and patient-centered care. METHODS This mixed-method study took place alongside a TB intervention implemented in Ho Chi Minh City, Viet Nam, between October-2017 - September-2019. The valuation encompassed beneficiary, health system and societal perspectives over a 5-year time-horizon. We conducted a rapid literature review, two focus group discussions and 14 in-depth interviews to identify and validate pertinent stakeholders and material value drivers. We compiled quantitative data from the TB program's and the intervention's surveillance systems, ecological databases, scientific publications, project accounts and 11 beneficiary surveys. We mapped, quantified and monetized value drivers to derive a crude financial benefit, which was adjusted for four counterfactuals. We calculated a SROI based on the net present value (NPV) of benefits and investments using a discounted cash flow model with a discount rate of 3.5%. A scenario analysis assessed SROI at varying discount rates of 0-10%. RESULTS The mathematical model yielded NPVs of US$235,511 in investments and US$8,497,183 in benefits. This suggested a return of US$36.08 for each dollar invested, ranging from US$31.66-US39.00 for varying discount rate scenarios. CONCLUSIONS The evaluated CHW-based TB intervention generated substantial individual and societal benefits. The SROI methodology may be an alternative for the economic evaluation of healthcare interventions.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jacqueline Tran
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Thu Dam
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jenny Driscoll
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Andrew James Codlin
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | | | - Kristi Sidney-Annerstedt
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Solna, Sweden
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13
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Xu C, Xia Y, Hu D, Zhang X, Zhao Y. Financial Burden of Tuberculosis Patients - China, 2020. China CDC Wkly 2023; 5:266-270. [PMID: 37138892 PMCID: PMC10150749 DOI: 10.46234/ccdcw2023.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 05/05/2023] Open
Abstract
What is already known about this topic? Tuberculosis (TB) is often referred to as "a disease of poverty," yet the information regarding the financial burden of TB care is limited and regionally representative. What is added by this report? This manuscript reported the national representative total and breakdown costs associated with TB care in China. The total cost per patient was 1,185 USD, of which 88% was direct cost and 37% was incurred prior to TB treatment. What are the implications for public health practice? TB patients experience a significant financial burden, and disparities exist among different regions and populations. Current TB care policies and packages are not sufficient to address this issue.
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Affiliation(s)
- Caihong Xu
- National Center for Tuberculosis Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Yinyin Xia
- National Center for Tuberculosis Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Dongmei Hu
- National Center for Tuberculosis Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | | | - Yanlin Zhao
- National Center for Tuberculosis Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
- Yanlin Zhao,
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14
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Matulyte E, Davidaviciene E, Kancauskiene Z, Diktanas S, Kausas A, Velyvyte D, Urboniene J, Lipnickiene V, Laurencikaite M, Danila E, Costagliola D, Matulionyte R. The socio-demographic, clinical characteristics and outcomes of tuberculosis among HIV infected adults in Lithuania: A thirteen-year analysis. PLoS One 2023; 18:e0282046. [PMID: 36952578 PMCID: PMC10035857 DOI: 10.1371/journal.pone.0282046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 02/06/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is a public health problem in Lithuania, among the 18 high-priority TB countries in the European region, and the most common AIDS-indicative disease with the highest proportion in the EU/EEA since 2015. The study aimed to identify socio-demographic, clinical characteristics and their relationship with TB outcomes in TB-HIV co-infected patients in Lithuania. METHODS A retrospective chart review analysed the characteristics of TB-HIV co-infected adults registered in State Information System of Tuberculosis over 2008-2020. The factors associated with drug-resistant TB and unsuccessful treatment outcome were identified by multivariable logistic regression. RESULTS The study included 345 cases in 311 patients (239 new, 106 previously treated cases), median age 40 years (IQR 35-45), 80.7% male. 67.8% patients knew their HIV-positive status before TB diagnosis, median time to TB diagnosis was 8 years (IQR 4-12). 83.6% were unemployed, 50.5%-anytime intravenous drug users (IDU), 34.9% abused alcohol. Drug-resistant TB rates in new and previously treated TB cases were 38.1% and 61.3%, respectively. In multivariable analysis, higher risk of drug-resistant TB was associated with imprisonment in new (aOR 3.35; 95%CI 1.17-9.57) and previously treated (aOR 6.63; 95%CI 1.09-40.35) cases. In 52.3% of new TB cases and in 42.5% previously treated TB cases the treatment outcomes were unsuccessful. In multivariable analysis of new TB cases, current imprisonment (aOR 2.77; 95%CI 1.29-5.91) and drug-resistant TB (aOR 2.18; 95%CI 1.11-4.28) were associated with unsuccessful treatment outcome. In multivariable analysis of previously treated TB cases, female gender (aOR 11.93; 95%CI 1.86-76.69), alcohol abuse (aOR 3.17; 95%CI 1.05-9.58), drug-resistant TB (aOR 4.83; 95%CI 1.53-15.28) were associated with unsuccessful treatment outcome. CONCLUSIONS In the TB-HIV-infected adult cohort in Lithuania, unemployment, imprisonment, IDU, alcohol abuse, known to be risk factors for TB, were very frequent. Drug resistance was an undeniable risk factor for unsuccessful treatment outcome and imprisonment was associated with drug resistant TB.
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Affiliation(s)
- Elzbieta Matulyte
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Infectious Diseases, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Edita Davidaviciene
- State Information System of Tuberculosis, Public Health Department, Ministry of Health, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Zavinta Kancauskiene
- AIDS Centre, Department of Infectious Diseases, University Hospital of Klaipeda, Klaipeda, Lithuania
| | - Saulius Diktanas
- Tuberculosis Department, Republican Klaipeda Hospital, Klaipeda, Lithuania
| | - Aidas Kausas
- Adult Infectious Diseases Unit, Clinic of Conservative Medicine, Republican Siauliai County Hospital, Siauliai, Lithuania
| | - Daiva Velyvyte
- Department of Infectious Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Kaunas Hospital of the Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jurgita Urboniene
- Centre of Infectious Diseases, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | | | | | - Edvardas Danila
- Clinic of Chest Diseases, Immunology, and Allergology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Dominique Costagliola
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie de Santé Publique, Paris, France
| | - Raimonda Matulionyte
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Infectious Diseases, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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15
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Rahman T, Gasbarro D, Alam K. Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature. Health Res Policy Syst 2022; 20:83. [PMID: 35906591 PMCID: PMC9336110 DOI: 10.1186/s12961-022-00886-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP. Results The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP. Conclusion The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00886-3.
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Affiliation(s)
- Taslima Rahman
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia. .,Institute of Health Economics, University of Dhaka, Dhaka, 1000, Bangladesh.
| | - Dominic Gasbarro
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia
| | - Khurshid Alam
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia
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Florentino JL, Arao RML, Garfin AMC, Gaviola DMG, Tan CR, Yadav RP, Hiatt T, Morishita F, Siroka A, Yamanaka T, Nishikiori N. Expansion of social protection is necessary towards zero catastrophic costs due to TB: The first national TB patient cost survey in the Philippines. PLoS One 2022; 17:e0264689. [PMID: 35226705 PMCID: PMC8884492 DOI: 10.1371/journal.pone.0264689] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 02/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Tuberculosis (TB) is a disease associated with poverty. Moreover, a significant proportion of TB patients face a substantial financial burden before and during TB care. One of the top targets in the End TB strategy was to achieve zero catastrophic costs due to TB by 2020. To assess patient costs related to TB care and the proportion of TB-affected households that faced catastrophic costs, the Philippines National TB Programme (NTP) conducted a national TB patient cost survey in 2016–2017. Methods A cross-sectional survey of 1,912 TB patients taking treatment in health facilities engaged with the NTP. The sample consists of 786 drug-sensitive TB (DS-TB) patients in urban facilities, 806 DS-TB patients in rural facilities, and 320 drug-resistant TB (DR-TB) patients. Catastrophic cost due to TB is defined as total costs, consisting of direct medical and non-medical costs and indirect costs net of social assistance, exceeding 20% of annual household income. Results The overall mean total cost including pre- and post-diagnostic costs was US$601. The mean total cost was five times higher among DR-TB patients than DS-TB patients. Direct non-medical costs and income loss accounted for 42.7% and 40.4% of the total cost of TB, respectively. More than 40% of households had to rely on dissaving, taking loans, or selling their assets to cope with the costs. Overall, 42.4% (95% confidence interval (95% CI): 40.2–44.6) of TB-affected households faced catastrophic costs due to TB, and it was significantly higher among DR-TB patients (89.7%, 95%CI: 86.3–93.0). A TB enabler package, which 70% of DR-TB patients received, reduced catastrophic costs by 13.1 percentage points (89.7% to 76.6%) among DR-TB patients, but only by 0.4 percentage points (42.4% to 42.0%), overall. Conclusions TB patients in the Philippines face a substantial financial burden due to TB despite free TB services provided by the National TB Programme. The TB enabler package mitigated catastrophic costs to some extent, but only for DR-TB patients. Enhancing the current social and welfare support through multisectoral collaboration is urgently required to achieve zero catastrophic costs due to TB.
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Affiliation(s)
- Jhiedon L. Florentino
- Health Policy Development Program (HPDP)-UPecon Foundation, Inc., Quezon City, Philippines
| | - Rosa Mia L. Arao
- Health Policy Development Program (HPDP)-UPecon Foundation, Inc., Quezon City, Philippines
- * E-mail:
| | | | | | - Carlos R. Tan
- Health Policy Development Program (HPDP)-UPecon Foundation, Inc., Quezon City, Philippines
| | | | - Tom Hiatt
- World Health Organization, Country Office, Manila, Philippines
| | - Fukushi Morishita
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Andrew Siroka
- World Health Organization, Global Tuberculosis Programme, Geneva, Switzerland
| | - Takuya Yamanaka
- World Health Organization, Global Tuberculosis Programme, Geneva, Switzerland
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Nobuyuki Nishikiori
- World Health Organization, Global Tuberculosis Programme, Geneva, Switzerland
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17
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Wrohan I, Nguyen TA, Nguyen VN, Nguyen BH, Hoang TTT, Nguyen PC, Velen K, Marks GB, Fox GJ. Predictors of treatment outcomes among patients with multidrug-resistant tuberculosis in Vietnam: a retrospective cohort study. BMC Infect Dis 2022; 22:68. [PMID: 35057754 PMCID: PMC8772201 DOI: 10.1186/s12879-021-06992-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Improving treatment outcomes for multidrug-resistant tuberculosis (MDR-TB) is a leading priority for global TB control. This retrospective cohort study evaluated the factors associated with treatment success among patients treated for MDR-TB in two provinces in Vietnam.
Methods
Treatment outcomes were evaluated for adult patients treated in Hanoi and Thanh Hoa provinces between 2014 and 2016. The primary outcome was the proportion of patients with treatment success, defined as cure or treatment completion. Logistic regression analysis was used to evaluate the relationship between patient clinical and microbiological characteristics and treatment success.
Results
Treatment outcomes were reported in 612 of 662 patients; of these, 401 (65.5)% were successfully treated. The odds of treatment success were lower for male patients (aOR 0.56, 95% CI 0.34–0.90), for people living with HIV (aOR 0.44, 95% CI 0.20–1.00), and for patients treated for extensive antibiotic resistance (pre-XDR-/XDT-TB) (aOR 0.53, 95% CI 0.29–0.97), compared with others. Patients who achieved culture conversion in the first 4 months of treatment had increased odds (aOR 2.93, 95% CI 1.33–6.45) of treatment success. In addition, loss to follow-up was less common among patients covered by social health insurance compared to those who paid for treatment out-of-pocket (aOR 0.55, 95% CI 0.32–0.95).
Conclusions
Among patients with MDR-TB, males, people living with HIV, and those with more extensive antibiotic resistance at diagnosis are at greatest risk of an unsuccessful treatment outcome. Efforts to optimise the management of co-morbidities (such as HIV), ensure rapid bacteriological conversion, and provide financial support for patients promise to improve treatment outcomes.
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18
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Ghazy RM, El Saeh HM, Abdulaziz S, Hammouda EA, Elzorkany AM, Khidr H, Zarif N, Elrewany E, Abd ElHafeez S. A systematic review and meta-analysis of the catastrophic costs incurred by tuberculosis patients. Sci Rep 2022; 12:558. [PMID: 35017604 PMCID: PMC8752613 DOI: 10.1038/s41598-021-04345-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
One of the strategies of the World Health Organization End Tuberculosis (TB) was to reduce the catastrophic costs incurred by TB-affected families to 0% by 2020.Catastrophic cost is defined by the total cost related to TB management exceeding 20% of the annual pre-TB household income. This study aimed to estimate the pooled proportion of TB affected households who incurred catastrophic costs. We searched PubMed, SciELO, Scopus, Embase, Google Scholar, ProQuest, SAGE, and Web of Science databases according to Preferred Reporting Items of the Systematic Reviews and Meta-Analysis (PRISMA) guidelines till November 20, 2020. Eligible studies were identified and data on catastrophic costs due to TB were extracted. We performed a meta-analysis to generate the pooled proportion of patients with TB facing catastrophic costs. From 5114 studies identified, 29 articles were included in the final analysis. The pooled proportion of patients faced catastrophic costs was (43%, 95% CI [34-51]). Meta-regression revealed that country, drug sensitivity, and Human immune-deficiency Virus (HIV) co-infection were the main predictors of such costs. Catastrophic costs incurred by drug sensitive, drug resistant, and HIV co-infection were 32%, 81%, and 81%, respectively. The catastrophic costs incurred were lower among active than passive case findings (12% vs. 30%). Half (50%) of TB-affected households faced catastrophic health expenditure at 10% cut-off point. The financial burden of patients seeking TB diagnosis and treatment continues to be a worldwide impediment. Therefore, the End TB approach should rely on socioeconomic support and cost-cutting initiatives.PROSPERO registration: CRD42020221283.
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Affiliation(s)
- Ramy Mohamed Ghazy
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Haider M El Saeh
- Community Medicine Department, Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | | | | | | | - Heba Khidr
- Ministry of Health and Population, Alexandria, Egypt
| | - Nardine Zarif
- Ministry of Health and Population, Alexandria, Egypt
| | - Ehab Elrewany
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Samar Abd ElHafeez
- Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
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19
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Tran PMT, Dam TA, Huynh HB, Codlin AJ, Forse RJ, Dang HMT, Truong VV, Nguyen LH, Nguyen HB, Nguyen NV, Creswell J, Meralli F, Morishita F, Dong TTT, Nguyen GH, Vo LNQ. Evaluating novel engagement mechanisms, yields and acceptability of tuberculosis screening at retail pharmacies in Ho Chi Minh City, Viet Nam. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000257. [PMID: 36962503 PMCID: PMC10021543 DOI: 10.1371/journal.pgph.0000257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 08/28/2022] [Indexed: 03/26/2023]
Abstract
Pharmacies represent a key health system entry point for people with TB in Viet Nam, but high fragmentation hinders their broader engagement. Professional networking apps may be able to facilitate pharmacy engagement for systematic TB screening and referral. Between September and December 2019, we piloted the use of a social networking app, SwipeRx, to recruit pharmacists for a TB referral scheme across four districts of Ho Chi Minh City, Viet Nam. We measured chest X-ray (CXR) referrals and TB detection yields at participating pharmacies and fielded 100 acceptability surveys, divided into pharmacists who did and did not make a CXR referral. We then fitted mixed-effect odds proportional models to explore acceptability factors that were associated with making a CXR referral. 1,816 push notifications were sent to pharmacists via the SwipeRx app and 78 indicated their interest in participating; however, only one was within the pilot's intervention area. Additional in-person outreach resulted in the recruitment of 146 pharmacists, with 54 (37.0%) making at least one CXR referral. A total of 182 pharmacy customers were referred, resulting in a total of 64 (35.2%) CXR screens and seven people being diagnosed with TB. Compared to pharmacists who did not make any CXR referrals, pharmacists making at least one CXR referral understood the pilot's objectives more clearly (aOR = 2.6, 95% CI: 1.2-5.8) and they believed that TB screening increased customer trust (aOR = 2.7, 95% CI: 1.2-5.8), benefited their business (aOR = 2.8, 95% CI: 1.3-6.2) and constituted a competitive advantage (aOR = 4.4, 95% CI: 1.9-9.9). They were also more confident in using mHealth apps (aOR = 3.1, 95 CI%: 1.4-6.8). Pharmacies can play an important role in early and increased TB case finding. It is critical to highlight the value proposition of TB referral schemes to their business during recruitment. Digital networking platforms, such as SwipeRx, can facilitate referrals for TB screening by pharmacists, but their ability to identify and recruit pharmacists requires optimization, particularly when targeting specific segments of a nation-wide digital network.
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Affiliation(s)
| | - Thu A Dam
- Friends for International TB Relief, Ha Noi, Viet Nam
| | - Huy B Huynh
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | | | - Ha M T Dang
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | - Vinh V Truong
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | - Lan H Nguyen
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | | | | | | | | | - Fukushi Morishita
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Thuy T T Dong
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | - Luan N Q Vo
- Friends for International TB Relief, Ha Noi, Viet Nam
- IRD VN, Ho Chi Minh City, Viet Nam
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20
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Kaswa M, Minga G, Nkiere N, Mingiedi B, Eloko G, Nguhiu P, Baena IG. The economic burden of TB-affected households in DR Congo. Int J Tuberc Lung Dis 2021; 25:923-932. [PMID: 34686235 PMCID: PMC8544924 DOI: 10.5588/ijtld.21.0182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND: The Democratic Republic of Congo’s free TB care policy and recent progress with universal health coverage are insufficient to remove barriers to TB care access and adherence. As there were no nationally representative data on the economic burden borne by TB patients, the TB programme conducted a national survey to assess the proportion of TB patients facing catastrophic costs, which could also serve as a baseline for monitoring progress. METHODS: A national survey with retrospective data collection and projection, following WHO methods, was administered to 1,118 patients in 43 treatment zones. Each patient was interviewed once on costs, time loss, coping measures, income, household expenditure and asset ownership. Total costs were expressed as a percentage of annual household expenditure. RESULTS: In 2019, 56.5% of households affected by TB experienced costs above 20% of their annual household expenditure. Mean costs amounted to respectively US$400 (range: 328–471) and US$1,224 (range: 762–1,686) per episode of first-line and drug-resistant TB. The risk of catastrophic costs increased with hospitalisation, drug resistance status and lower economic status. Half of households resorted to coping strategies and experienced food insecurity. Only 7.5% received social support. CONCLUSION: TB-affected households incur on average a cost of US$549, despite free TB care policy. Mitigating this burden with medical cost reductions, social and labour market measures will be key.
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Affiliation(s)
- M Kaswa
- Programme National de Lutte contre la Tuberculose, Ministére de la Santé Publique, Kinshasa, DR Congo, Service de Microbiologie, Département de Biologie médicale, Université de Kinshasa, Kinshasa, DR Congo
| | - G Minga
- World Health Organization, DR Congo Office, Kinshasa, DR Congo
| | - N Nkiere
- World Health Organization, DR Congo Office, Kinshasa, DR Congo
| | - B Mingiedi
- Institut National de Statistique, Ministère du Plan, Kinshasa, DR Congo
| | - G Eloko
- Programme National des Comptes Nationaux de la Santé, Ministère de la Santé Publique, Kinshasa, DR Congo
| | - P Nguhiu
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - I Garcia Baena
- Global TB Programme, World Health Organization, Geneva, Switzerland
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21
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Viney K, Itogo N, Yamanaka T, Jebeniani R, Hazarika A, Morishita F, Nishikiori N, Nery SV. Economic evaluation of patient costs associated with tuberculosis diagnosis and care in Solomon Islands. BMC Public Health 2021; 21:1928. [PMID: 34688266 PMCID: PMC8542301 DOI: 10.1186/s12889-021-11938-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) care can be costly for patients and their families. The End TB Strategy includes a target that zero TB affected households should experience catastrophic costs associated with TB care. Costs are catastrophic when a patient spends 20% or more of their annual household income on their TB diagnosis and care. In Solomon Islands the costs of TB care are unknown. The aim of this study was to determine the costs of TB diagnosis and care, the types of costs and the proportion of patients with catastrophic costs. METHODS This was a nationally representative cross-sectional survey of TB patients carried out between 2017 and 2019. Patients were recruited from health care facilities, from all ten provinces in Solomon Islands. During an interview they were asked about the costs of TB diagnosis and care. These data were analysed using descriptive statistics to describe the costs overall and the proportions of different types of costs. The proportion of patients with catastrophic costs was calculated and a multivariate logistic regression was undertaken to determine factors associated with catastrophic costs. RESULTS One hundred and eighty-three TB patients participated in the survey. They spent a mean of 716 USD (inter quartile range: 348-1217 USD) on their TB diagnosis and care. Overall, 62.1% of costs were attributable to non-medical costs, while income loss and medical costs comprised 28.5 and 9.4%, respectively. Overall, 19.7% (n = 36) of patients used savings, borrowed money, or sold assets as a financial coping mechanism. Three patients (1.6%) had health insurance. A total of 92.3% (95% CI: 88.5-96.2) experienced catastrophic costs, using the output approach. Being in the first, second or third poorest wealth quintile was significantly associated with catastrophic costs (adjusted odds ratio: 67.3, 95% CI: 15.86-489.74%, p < 0.001). CONCLUSION The costs of TB care are catastrophic for almost all patients in Solomon Islands. The provision of TB specific social and financial protection measures from the National TB and Leprosy Programme may be needed in the short term to ameliorate these costs. In the longer term, advancement of universal health coverage and other social and financial protection measures should be pursued.
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Affiliation(s)
- Kerri Viney
- Research School of Population Health, Australian National University, Canberra, Australia.
- Global TB Programme, World Health Organization Headquarters, Geneva, Switzerland.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Noel Itogo
- National TB Programme, Ministry of Health and Medical Services, Honiara, Solomon Islands
- World Health Organization Country Office, Honiara, Solomon Islands
| | - Takuya Yamanaka
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- School of Tropical Medicine & Global Health, Nagasaki University, Nagasaki, Japan
| | | | - Anupama Hazarika
- World Health Organization Country Office, Honiara, Solomon Islands
| | - Fukushi Morishita
- End TB and Leprosy Unit, World Health Organization Regional Office of the Western Pacific, Manila, Philippines
| | - Nobuyuki Nishikiori
- Global TB Programme, World Health Organization Headquarters, Geneva, Switzerland
| | - Susana Vaz Nery
- Research School of Population Health, Australian National University, Canberra, Australia
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
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22
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Vo LNQ, Forse RJ, Codlin AJ, Dang HM, Van Truong V, Nguyen LH, Nguyen HB, Nguyen NV, Sidney-Annerstedt K, Lonnroth K, Squire SB, Caws M, Worrall E, de Siqueira-Filha NT. Socio-protective effects of active case finding on catastrophic costs from tuberculosis in Ho Chi Minh City, Viet Nam: a longitudinal patient cost survey. BMC Health Serv Res 2021; 21:1051. [PMID: 34610841 PMCID: PMC8493691 DOI: 10.1186/s12913-021-06984-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many tuberculosis (TB) patients incur catastrophic costs. Active case finding (ACF) may have socio-protective properties that could contribute to the WHO End TB Strategy target of zero TB-affected families suffering catastrophic costs, but available evidence remains limited. This study measured catastrophic cost incurrence and socioeconomic impact of an episode of TB and compared those socioeconomic burdens in patients detected by ACF versus passive case finding (PCF). METHODS This cross-sectional study fielded a longitudinal adaptation of the WHO TB patient cost survey alongside an ACF intervention from March 2018 to March 2019. The study was conducted in six intervention (ACF) districts and six comparison (PCF) districts of Ho Chi Minh City, Viet Nam. Fifty-two TB patients detected through ACF and 46 TB patients in the PCF cohort were surveyed within two weeks of treatment initiation, at the end of the intensive phase of treatment, and after treatment concluded. The survey measured income, direct and indirect costs, and socioeconomic impact based on which we calculated catastrophic cost as the primary outcome. Local currency was converted into US$ using the average exchange rates reported by OANDA for the study period (VNĐ1 = US$0.0000436, 2018-2019). We fitted logistic regressions for comparisons between the ACF and PCF cohorts as the primary exposures and used generalized estimating equations to adjust for autocorrelation. RESULTS ACF patients were poorer than PCF patients (multidimensional poverty ratio: 16 % vs. 7 %; p = 0.033), but incurred lower median pre-treatment costs (US$18 vs. US$80; p < 0.001) and lower median total costs (US$279 vs. US$894; p < 0.001). Fewer ACF patients incurred catastrophic costs (15 % vs. 30 %) and had lower odds of catastrophic cost (aOR = 0.17; 95 % CI: [0.05, 0.67]; p = 0.011), especially during the intensive phase (OR = 0.32; 95 % CI: [0.12, 0.90]; p = 0.030). ACF patient experienced less social exclusion (OR = 0.41; 95 % CI: [0.18, 0.91]; p = 0.030), but more often resorted to financial coping mechanisms (OR = 5.12; 95 % CI: [1.73, 15.14]; p = 0.003). CONCLUSIONS ACF can be effective in reaching vulnerable populations and mitigating the socioeconomic burden of TB, and can contribute to achieving the WHO End TB Strategy goals. Nevertheless, as TB remains a catastrophic life event, social protection efforts must extend beyond ACF.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Vietnam. .,IRD VN, Ho Chi Minh City, Vietnam.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Vietnam.,Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Andrew James Codlin
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Vietnam
| | - Ha Minh Dang
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | | | | | | | | | | | - Knut Lonnroth
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - S Bertel Squire
- Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, UK
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, UK.,Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Eve Worrall
- Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, UK
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23
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Haldane V, Zhang Z, Ma Q, Yin T, Zhang B, Li Y, Pan Q, Dainty KN, Rea E, Pasang P, Wei X, Hu J. A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China. Infect Dis Poverty 2021; 10:120. [PMID: 34544492 PMCID: PMC8451167 DOI: 10.1186/s40249-021-00906-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculosis (TB) is a major global health threat and the leading infectious disease cause of death worldwide. Access to and retention in TB care remains a challenge for patients, particularly those living in rural and remote settings. This qualitative study explored barriers and facilitators to accessing and maintaining contact with TB care services in communities in Xigaze (Shigatse) prefecture, Xizang Autonomous Region (Tibet Autonomous Region), China from the perspective of persons impacted by TB. Methods We conduced in-depth interviews with 23 participants impacted by TB in four rural districts in Xigaze prefecture, Xizang Autonomous Region, China between April 2019 and November 2020. Interviews were conducted in Tibetan and Mandarin, transcribed in Mandarin and translated into English. Transcripts were checked against recordings by native Tibetan and Mandarin speakers. QSR NVivo12 software was used for framework analysis guided by an access to care conceptual framework by Levesque et al. Results Overall patients reported low awareness of and an indifferent attitude towards TB, although all reported understanding the need to adhere to treatment. Participants reported complex pathways to care, often requiring visits to multiple healthcare facilities. Some participants reported visiting traditional Tibetan medicine (TTM) providers. Participants reported various barriers to accessing care including challenges physically reaching care, out-of-pocket payments for tests, diagnostics and transport. Barriers to maintaining care included medication side effects and worry about treatment effectiveness. Enablers to accessing care identified included knowledge or past experience with TB, integrated models of TTM and western care, supportive village doctors who conducted home visits, free TB treatment and other subsidies, as well as having family support with care and social support as barriers and facilitators to maintaining treatment. Conclusions We identified barriers and facilitators to accessing services in rural communities in Xigaze from the perspective of persons impacted by TB. Challenges include complex pathways to care, travel distances, wait times and low awareness. Tuberculosis care in the region could be strengthened by ongoing culturally tailored educational campaigns to increase awareness, partnerships with TTM providers, providing comprehensive treatment subsidies and strengthening the role of family members in comprehensive TB care. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00906-4.
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Affiliation(s)
- Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Qi Ma
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Tingting Yin
- Weifang Medical College, Weifang, Shandong, China
| | - Bei Zhang
- Weifang Medical College, Weifang, Shandong, China
| | - Yinlong Li
- Jining Medical University, Jining, Shandong, China
| | - Qiuyu Pan
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Katie N Dainty
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Elizabeth Rea
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Pande Pasang
- Xigaze Centre for Disease Control and Prevention, 7 Keji Road, Sangzhuzi District, Xigaze, Xizang, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada.
| | - Jun Hu
- Shandong University of Traditional Chinese Medicine, Jinan, 250355, China.
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24
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Pedroso MRDO, Guidoni LM, Zandonade E, Fregona G, Negri LDSA, Oliveira SMDVLD, Prado TND, Sales CMM, Coimbra RDS, Galavote HS, Maciel ELN. Catastrophic costs and social sequels due to tuberculosis diagnosis and treatment in Brazil. EPIDEMIOLOGIA E SERVIÇOS DE SAÚDE 2021; 30:e2020810. [PMID: 34287550 DOI: 10.1590/s1679-49742021000300012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 02/09/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the impact of catastrophic costs on unfavorable tuberculosis treatment outcomes. METHODS This was a prospective cohort study, conducted in five Brazilian state capitals (Manaus, Recife, Vitória, Campo Grande and Porto Alegre) from June 2016 to July 2018. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (95%CI). RESULTS Of the 350 participants, 310 were included, of whom 30 presented unfavorable outcomes. Catastrophic cost (OR=2.53 -95% CI 1.13;5.67) and divorce (OR=5.29 -95% CI 1.39;20.05) increased the chances of unfavorable outcomes. CONCLUSION Financial difficulties during tuberculosis treatment may impair its outcome. Catastrophic cost and divorce were determining factors for treatment outcomes.
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Affiliation(s)
| | - Leticia Molino Guidoni
- Universidade Federal do Espírito Santo, Laboratório de Epidemiologia, Vitória, ES, Brasil
| | - Eliana Zandonade
- Universidade Federal do Espírito Santo, Programa de Pós-Graduação em Saúde Coletiva, Vitória, ES, Brasil
| | - Geisa Fregona
- Universidade Federal do Espírito Santo, Programa de Pós-Graduação em Saúde Coletiva, Vitória, ES, Brasil
| | | | | | | | | | | | | | - Ethel Leonor Noia Maciel
- Universidade Federal do Espírito Santo, Programa de Pós-Graduação em Saúde Coletiva, Vitória, ES, Brasil
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25
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Timire C, Ngwenya M, Chirenda J, Metcalfe JZ, Kranzer K, Pedrazzoli D, Takarinda KC, Nguhiu P, Madzingaidzo G, Ndlovu K, Mapuranga T, Cornell M, Sandy C. Catastrophic costs among tuberculosis-affected households in Zimbabwe: a national health facility-based survey. Trop Med Int Health 2021; 26:1248-1255. [PMID: 34192392 DOI: 10.1111/tmi.13647] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine the incidence and major drivers of catastrophic costs among TB-affected households in Zimbabwe. METHODS We conducted a nationally representative health facility-based survey with random cluster sampling among consecutively enrolled drug-susceptible (DS-TB) and drug-resistant TB (DR-TB) patients. Costs incurred and income lost due to TB illness were captured using an interviewer-administered standardised questionnaire. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs. RESULTS A total of 841 patients were enrolled and were weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI: 77-82) of TB patients and their households experienced catastrophic costs. The major cost driver pre-TB diagnosis was direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, with a median cost of US$360 (IQR: 240-600). Post-TB median diagnosis costs were three times higher among DR-TB (US$1,659 [653-2,787]) than drug DS-TB-affected households (US$537 [204-1,134]). Income loss was five times higher among DR-TB than DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: The poorest households had 16 times the odds of incurring catastrophic costs versus the wealthiest households (adjusted odds ratio [aOR: 15.7 95% CI: 7.5-33.1]). CONCLUSION The majority of TB-affected households, especially those affected by DR-TB, experienced catastrophic costs. Since the major cost drivers fall outside the healthcare system, multi-sectoral approaches to TB control and linking TB patients to social protection may reduce catastrophic costs.
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Affiliation(s)
- Collins Timire
- AIDS & TB Control Programme, Ministry of Health and Child Care, Harare, Zimbabwe.,International Union Against Tuberculosis and Lung Disease, Paris, France.,Faculty of Infectious & Tropical Diseases, London School of Hygiene &Tropical Medicine, London, UK
| | - Mkhokheli Ngwenya
- Zimbabwe Country Office, World Health Organization, Harare, Zimbabwe
| | - Joconiah Chirenda
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - John Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, USA
| | - Katharina Kranzer
- Faculty of Infectious & Tropical Diseases, London School of Hygiene &Tropical Medicine, London, UK
| | - Debora Pedrazzoli
- Faculty of Epidemiology & Population Health, London School of Hygiene &Tropical Medicine, London, UK.,World Health Organization, Geneva, Switzerland
| | - Kudakwashe C Takarinda
- AIDS & TB Control Programme, Ministry of Health and Child Care, Harare, Zimbabwe.,International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Peter Nguhiu
- Health Economics Research Unit, Kenya Medical Research Institute, Wellcome Trust Research Programme, Nairobi, Kenya
| | - Geshem Madzingaidzo
- AIDS & TB Control Programme, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Tawanda Mapuranga
- AIDS & TB Control Programme, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Charles Sandy
- AIDS & TB Control Programme, Ministry of Health and Child Care, Harare, Zimbabwe
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Gurung SC, Rai B, Dixit K, Worrall E, Paudel PR, Dhital R, Sah MK, Pandit RN, Aryal TP, Majhi G, Wingfield T, Squire B, Lönnroth K, Levy JW, Viney K, van Rest J, Ramsay A, Santos da Costa RM, Basnyat B, Thapa A, Mishra G, Moreira Pescarini J, Caws M, Teixeira de Siqueira-Filha N. How to reduce household costs for people with tuberculosis: a longitudinal costing survey in Nepal. Health Policy Plan 2021; 36:594-605. [PMID: 33341891 PMCID: PMC8173598 DOI: 10.1093/heapol/czaa156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to compare costs and socio-economic impact of tuberculosis (TB) for patients diagnosed through active (ACF) and passive case finding (PCF) in Nepal. A longitudinal costing survey was conducted in four districts of Nepal from April 2018 to October 2019. Costs were collected using the WHO TB Patient Costs Survey at three time points: intensive phase of treatment, continuation phase of treatment and at treatment completion. Direct and indirect costs and socio-economic impact (poverty headcount, employment status and coping strategies) were evaluated throughout the treatment. Prevalence of catastrophic costs was estimated using the WHO threshold. Logistic regression and generalized estimating equation were used to evaluate risk of incurring high costs, catastrophic costs and socio-economic impact of TB over time. A total of 111 ACF and 110 PCF patients were included. ACF patients were more likely to have no education (75% vs 57%, P = 0.006) and informal employment (42% vs 24%, P = 0.005) Compared with the PCF group, ACF patients incurred lower costs during the pretreatment period (mean total cost: US$55 vs US$87, P < 0.001) and during the pretreatment plus treatment periods (mean total direct costs: US$72 vs US$101, P < 0.001). Socio-economic impact was severe for both groups throughout the whole treatment, with 32% of households incurring catastrophic costs. Catastrophic costs were associated with 'no education' status [odds ratio = 2.53(95% confidence interval = 1.16-5.50)]. There is a severe and sustained socio-economic impact of TB on affected households in Nepal. The community-based ACF approach mitigated costs and reached the most vulnerable patients. Alongside ACF, social protection policies must be extended to achieve the zero catastrophic costs milestone of the End TB strategy.
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Affiliation(s)
- Suman Chandra Gurung
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Bhola Rai
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | - Kritika Dixit
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
| | - Eve Worrall
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Puskar Raj Paudel
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB, Den Haag, the The Netherlands
| | - Raghu Dhital
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | - Manoj Kumar Sah
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | | | | | - Govinda Majhi
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | - Tom Wingfield
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
| | - Bertie Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Knut Lönnroth
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
| | - Jens W Levy
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB, Den Haag, the The Netherlands
| | - Kerri Viney
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
- Australian National University, Research School of Population Health, College of Health & Medicine, Canberra, ACT 2600, Australia
| | - Job van Rest
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB, Den Haag, the The Netherlands
| | - Andrew Ramsay
- University of St Andrews, College Gate St Andrews, KY16 9AJ, UK
| | - Rafaely Marcia Santos da Costa
- Oswaldo Cruz Foundation, Centro de Pesquisa Aggeu Magalhaes, Av. Professor Moraes Rego, s/n – Cidade Universitária – Recife/PE, CEP 50.740-465, Brazil
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, P. O. Box 26500, Kathmandu, Nepal
| | - Anil Thapa
- National Tuberculosis Control Centre, Thimi, Bhaktapur, Nepal
| | - Gokul Mishra
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Julia Moreira Pescarini
- Oswaldo Cruz Foundation, Centro de Integracao de Dados e Conhecimentos para Saude, Rua Mundo, 121, Trobogy, Salvador - Bahia, CEP 41745-715, Brazil
| | - Maxine Caws
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Noemia Teixeira de Siqueira-Filha
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
- University of York, Department of Helarh Sciences, Heslington, YO10 5DD, York, UK
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Nguyen LH, Tran PTM, Dam TA, Forse RJ, Codlin AJ, Huynh HB, Dong TTT, Nguyen GH, Truong VV, Dang HTM, Nguyen TD, Nguyen HB, Nguyen NV, Khan A, Creswell J, Vo LNQ. Assessing private provider perceptions and the acceptability of video observed treatment technology for tuberculosis treatment adherence in three cities across Viet Nam. PLoS One 2021; 16:e0250644. [PMID: 33961645 PMCID: PMC8104441 DOI: 10.1371/journal.pone.0250644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background The World Health Organization recently recommended Video Observed Therapy (VOT) as one option for monitoring tuberculosis (TB) treatment adherence. There is evidence that private sector TB treatment has substandard treatment follow-up, which could be improved using VOT. However, acceptability of VOT in the private sector has not yet been evaluated. Methods We conducted a cross-sectional survey employing a theoretical framework for healthcare intervention acceptability to measure private provider perceptions of VOT across seven constructs in three cities of Viet Nam: Ha Noi, Ho Chi Minh City, and Hai Phong. We investigated the differences in private providers’ attitudes and perceptions of VOT using mixed ordinal models to test for significant differences in responses between groups of providers stratified by their willingness to use VOT. Results A total of 79 private providers completed the survey. Sixty-two providers (75%) indicated they would use VOT if given the opportunity. Between private providers who would and would not use VOT, there were statistically significant differences (p≤0.001) in the providers’ beliefs that VOT would help identify side effects faster and in their confidence to monitor treatment and provide differentiated care with VOT. There were also significant differences in providers’ beliefs that VOT would save them time and money, address problems faced by their patients, benefit their practice and patients, and be relevant for all their patients. Conclusion Private providers who completed the survey have positive views towards using VOT and specific subpopulations acknowledge the value of integrating VOT into their practice. Future VOT implementation in the private sector should focus on emphasizing the benefits and relevance of VOT during recruitment and provide programmatic support for implementing differentiated care with the technology.
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Affiliation(s)
| | | | - Thu Anh Dam
- Friends for International TB Relief, Hanoi, Viet Nam
| | | | | | - Huy Ba Huynh
- Friends for International TB Relief, Hanoi, Viet Nam
| | | | | | | | | | | | | | | | - Amera Khan
- Stop TB Partnership, Geneva, Switzerland
| | | | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Hanoi, Viet Nam
- IRD VN, Hanoi, Viet Nam
- * E-mail:
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Ghazy RM, Saeh HME, Abdulaziz S, Hammouda EA, Elzorkany A, Kheder H, Zarif N, Elrewany E, Elhafeez SA. A Systematic Review and Meta-Analysis on Catastrophic Cost incurred by Tuberculosis Patients and their Households.. [DOI: 10.1101/2021.02.27.21252453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
AbstractBackgroundAs one of the World Health Organization (WHO) End Tuberculosis (TB) Strategy is to reduce the proportion of TB affected families that face catastrophic costs to 0% by 2020. This systematic review and meta-analysis aimed to estimate the pooled proportion of TB affected households who face catastrophic cost.MethodA search of the online database through September 2020 was performed. A total of 5114 articles were found, of which 29 articles got included in quantitative synthesis. Catastrophic cost is defined if total cost related to TB exceeded 20% of annual pre-TB household income. R software was used to estimate the pooled proportion at 95% confidence intervals (CIs) using the fixed/random-effect models.ResultThe proportion of patients faced catastrophic cost was 43% (95% CI 34-52, I2= 99%); 32% (95% CI 29 – 35, I2= 70%) among drug sensitive, and 80% (95% CI 74-85, I2= 54%) among drug resistant, and 81% (95%CI 78-84%, I2= 0%) among HIV patients. Regarding active versus passive case finding the pooled proportion of catastrophic cost was 12% (95% CI 9-16, I2= 95%) versus 42% (95% CI 35-50, I2= 94%). The pooled proportion of direct cost to the total cost was 45% (95% CI 39-51, I2= 91%). The pooled proportion of patients facing catastrophic health expenditure (CHE) at cut of point of 10% of their yearly income was 45% (95% CI 35-56, I2= 93%) while at 40% of their capacity to pay was 63% (95% CI 40-80, I2= 96%).ConclusionDespite the ongoing efforts, there is a significant proportion of patients facing catastrophic cost, which represent a main obstacle against TB control.PROSPERO registrationCRD42020221283
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Guidoni LM, Negri LDSA, Carlesso GF, Zandonade E, Maciel ELN. Custos catastróficos em pacientes com tuberculose no Brasil: estudo em cinco capitais. ESCOLA ANNA NERY 2021. [DOI: 10.1590/2177-9465-ean-2020-0546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo avaliar o impacto econômico domiciliar do adoecimento pela tuberculose no Brasil. Método pesquisa transversal multicêntrica de 2016 a 2018, em cinco capitais do Brasil, em pacientes diagnosticados com tuberculose. Os custos totais foram a soma dos custos diretos e indiretos incorridos antes e durante o diagnóstico e tratamento. A regressão logística foi utilizada para estudar determinantes de custos catastróficos. A pobreza foi medida como renda familiar per capita diária < U$ 5,5. Resultados trezentos e sessenta e um pacientes foram inscritos no estudo. O custo extrapolação foi de R$3.664,47 (DP: R$ 2.667,67) e o custo total de extrapolação foi de R$22.291,82 (DP: R$ 16.259,50). No geral, 29% dos participantes do estudo foram caracterizados como pobres antes da tuberculose, e 39% depois. Em média, a renda diminuiu em 11% dos participantes e 41% tiveram custos catastróficos. Os determinantes estatisticamente significativos de experimentar custos catastróficos foram: participante ser o chefe da família, vivendo na pobreza antes da tuberculose, desemprego e interrupção do trabalho durante o tratamento (p < 0,05). Conclusão e implicações para a prática embora o tratamento seja financiado pelo governo, a tuberculose continua resultando em custos catastróficos e diminuição da renda para muitas famílias no Brasil.
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Fuady A, Houweling TAJ, Richardus JH. COVID-19 and Tuberculosis-Related Catastrophic Costs. Am J Trop Med Hyg 2020; 104:436-440. [PMID: 33269683 PMCID: PMC7866313 DOI: 10.4269/ajtmh.20-1125] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/23/2020] [Indexed: 12/13/2022] Open
Abstract
The COVID-19 pandemic has created an unprecedented health crisis and a substantial socioeconomic impact. It also affects tuberculosis (TB) control severely worldwide. Interruptions of many TB control programs because of the COVID-19 pandemic could result in significant setbacks. One of the targets that can be affected is the WHO's End TB Strategy goal to eliminate catastrophic costs of TB-affected households by 2030. Disruptions to TB programs and healthcare services due to COVID-19 could potentially prolong diagnostic delays and worsen TB treatment adherence and outcomes. The economic recession caused by the pandemic could significantly impact household financial capacity because of the reduction of income and the rise in unemployment rates. All of these factors increase the risk of TB incidence and the gravity of economic impact on TB-affected households, and hamper efforts to eliminate catastrophic costs and control TB. Therefore, efforts to eliminate the incidence of TB-affected households facing catastrophic costs will be very challenging. Because financial constraint plays a significant role in TB control, the improvement of health and social protection systems is critical. Even before the pandemic, many TB-high-burden countries (HBCs) lacked robust health and social protection systems. These challenges highlight the substantial need for a more robust engagement of patients and civil society organizations and international support in addressing the consequences of COVID-19 on the control of TB.
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Affiliation(s)
- Ahmad Fuady
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Tanja A. J. Houweling
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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31
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Mac TH, Phan TH, Nguyen VV, Dong TTT, Le HV, Nguyen QD, Nguyen TD, Codlin AJ, Mai TDT, Forse RJ, Nguyen LP, Luu THT, Nguyen HB, Nguyen NV, Pham XT, Tran PN, Khan A, Vo LNQ, Creswell J. Optimizing Active Tuberculosis Case Finding: Evaluating the Impact of Community Referral for Chest X-ray Screening and Xpert Testing on Case Notifications in Two Cities in Viet Nam. Trop Med Infect Dis 2020; 5:tropicalmed5040181. [PMID: 33265972 PMCID: PMC7709663 DOI: 10.3390/tropicalmed5040181] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/07/2020] [Indexed: 11/25/2022] Open
Abstract
To accelerate the reduction in tuberculosis (TB) incidence, it is necessary to optimize the use of innovative tools and approaches available within a local context. This study evaluated the use of an existing network of community health workers (CHW) for active case finding, in combination with mobile chest X-ray (CXR) screening events and the expansion of Xpert MTB/RIF testing eligibility, in order to reach people with TB who had been missed by the current system. A controlled intervention study was conducted from January 2018 to March 2019 in five intervention and four control districts of two low to medium TB burden cities in Viet Nam. CHWs screened and referred eligible persons for CXR to TB care facilities or mobile screening events in the community. The initial diagnostic test was Xpert MTB/RIF for persons with parenchymal abnormalities suggestive of TB on CXR or otherwise on smear microscopy. We analyzed the TB care cascade by calculating the yield and number needed to screen (NNS), estimated the impact on TB notifications and conducted a pre-/postintervention comparison of TB notification rates using controlled, interrupted time series (ITS) analyses. We screened 30,336 individuals in both cities to detect and treat 243 individuals with TB, 88.9% of whom completed treatment successfully. All forms of TB notifications rose by +18.3% (95% CI: +15.8%, +20.8%). The ITS detected a significant postintervention step-increase in the intervention area for all-form TB notification rates (IRR(β6) = 1.221 (95% CI: 1.011, 1.475); p = 0.038). The combined use of CHWs for active case findings and mobile CXR screening expanded the access to and uptake of Xpert MTB/RIF testing and resulted in a significant increase in TB notifications. This model could serve as a blueprint for expansion throughout Vietnam. Moreover, the results demonstrate the need to optimize the use of the best available tools and approaches in order to end TB.
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Affiliation(s)
- Tuan Huy Mac
- Hai Phong Lung Hospital, Hai Phong 180000, Vietnam; (T.H.M.); (T.D.N.)
| | - Thuc Huy Phan
- Provincial Department of Health, Hai Phong 180000, Vietnam; (T.H.P.); (Q.D.N.); (X.T.P.)
| | - Van Van Nguyen
- Provincial Department of Health, Quang Nam 560000, Vietnam;
| | - Thuy Thu Thi Dong
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (T.T.T.D.); (A.J.C.); (T.D.T.M.); (R.J.F.); (L.P.N.)
| | - Hoi Van Le
- Viet Nam National Lung Hospital, Ha Noi 100000, Vietnam; (H.V.L.); (H.B.N.); (N.V.N.)
| | - Quan Duc Nguyen
- Provincial Department of Health, Hai Phong 180000, Vietnam; (T.H.P.); (Q.D.N.); (X.T.P.)
| | - Tho Duc Nguyen
- Hai Phong Lung Hospital, Hai Phong 180000, Vietnam; (T.H.M.); (T.D.N.)
| | - Andrew James Codlin
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (T.T.T.D.); (A.J.C.); (T.D.T.M.); (R.J.F.); (L.P.N.)
| | - Thuy Doan To Mai
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (T.T.T.D.); (A.J.C.); (T.D.T.M.); (R.J.F.); (L.P.N.)
| | - Rachel Jeanette Forse
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (T.T.T.D.); (A.J.C.); (T.D.T.M.); (R.J.F.); (L.P.N.)
| | - Lan Phuong Nguyen
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (T.T.T.D.); (A.J.C.); (T.D.T.M.); (R.J.F.); (L.P.N.)
| | | | - Hoa Binh Nguyen
- Viet Nam National Lung Hospital, Ha Noi 100000, Vietnam; (H.V.L.); (H.B.N.); (N.V.N.)
| | - Nhung Viet Nguyen
- Viet Nam National Lung Hospital, Ha Noi 100000, Vietnam; (H.V.L.); (H.B.N.); (N.V.N.)
| | - Xanh Thu Pham
- Provincial Department of Health, Hai Phong 180000, Vietnam; (T.H.P.); (Q.D.N.); (X.T.P.)
| | - Phap Ngoc Tran
- Pham Ngoc Thach Quang Nam Hospital, Quang Nam 560000, Vietnam;
| | - Amera Khan
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (J.C.)
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (T.T.T.D.); (A.J.C.); (T.D.T.M.); (R.J.F.); (L.P.N.)
- Interactive Research and Development, Singapore 189677, Singapore
- Correspondence: ; Tel.: +84-902-908004
| | - Jacob Creswell
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (J.C.)
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McAllister SM, Wiem Lestari B, Sullivan T, Fortuna Hadisoemarto P, Afifah N, Arosdiani Apip R, Murray M, Hill PC, Alisjahbana B. Out-of-Pocket Costs for Patients Diagnosed with Tuberculosis in Different Healthcare Settings in Bandung, Indonesia. Am J Trop Med Hyg 2020; 103:1057-1064. [PMID: 32618253 DOI: 10.4269/ajtmh.19-0848] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Costs related to tuberculosis (TB) can impose a significant burden on patients and their families and create barriers to diagnosis and treatment. Our study aimed to quantify out-of-pocket costs expended by TB patients in Bandung, Indonesia. This cross-sectional study recruited adults with TB from community health centers (CHCs), public and private hospitals, and private practitioners (PPs). An interview was completed at the time of diagnosis or at their return for 2- or 6-month treatment. Costs were converted to U.S. dollars (US$)-presented as median and interquartile range (IQR). Of 469 TB patients recruited, the mean age was 38 years and 57% were male. The median pretreatment direct cost per person was $37.51 (IQR 20.79-71.24). Hospitalization, diagnostic tests, and travel costs were predominant. Higher pretreatment costs were associated with no health insurance ($41.88 versus $27.41, P < 0.001), ≥ 6 visits to a healthcare provider ($39.91 versus $24.32, P < 0.001), ≥ 60 days pretreatment ($36.35 versus $26.25, P = 0.02), and presenting first to a PP ($40.71) or informal provider ($32.72) compared with private hospital ($21.26), public hospital ($19.63), or CHC ($13.52) (P = 0.01). For a subsample of 106 patients with total pre- and posttreatment costs available, the median total cost was $243.66 (IQR 128.46-550.71). For 26.5% of these patients, total costs were ≥ 20% of their annual household income. Despite having a good network of free TB diagnostic and treatment services throughout Bandung, patients experienced significant out-of-pocket costs. Increased uptake of the National Health Insurance, and systems for early recognition and diagnosis of TB, will contribute toward reducing costs.
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Affiliation(s)
- Susan M McAllister
- Center for International Health, University of Otago, Dunedin, New Zealand
| | - Bony Wiem Lestari
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Tuberculosis Working Group, Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Trudy Sullivan
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Panji Fortuna Hadisoemarto
- Tuberculosis Working Group, Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Nur Afifah
- Tuberculosis Working Group, Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rosye Arosdiani Apip
- Division of Disease Control and Prevention, Bandung Municipal Health Office, Bandung, Indonesia
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Philip C Hill
- Center for International Health, University of Otago, Dunedin, New Zealand
| | - Bachti Alisjahbana
- Department of Internal Medicine, Faculty of Medicine, Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia.,Tuberculosis Working Group, Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Chittamany P, Yamanaka T, Suthepmany S, Sorsavanh T, Siphanthong P, Sebert J, Viney K, Vixaysouk T, Nagai M, Seevisay V, Izumi K, Morishita F, Nishikiori N. First national tuberculosis patient cost survey in Lao People's Democratic Republic: Assessment of the financial burden faced by TB-affected households and the comparisons by drug-resistance and HIV status. PLoS One 2020; 15:e0241862. [PMID: 33180777 PMCID: PMC7660466 DOI: 10.1371/journal.pone.0241862] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/22/2020] [Indexed: 12/16/2022] Open
Abstract
Background Tuberculosis (TB) patients incur large costs for care seeking, diagnosis, and treatment. To understand the magnitude of this financial burden and its main cost drivers, the Lao People’s Democratic Republic (PDR) National TB Programme carried out the first national TB patient cost survey in 2018–2019. Method A facility-based cross-sectional survey was conducted based on a nationally representative sample of TB patients from public health facilities across 12 provinces. A total of 848 TB patients including 30 drug resistant (DR)-TB and 123 TB-HIV coinfected patients were interviewed using a standardised questionnaire developed by the World Health Organization. Information on direct medical, direct non-medical and indirect costs, as well as coping mechanisms was collected. We estimated the percentage of TB-affected households facing catastrophic costs, which was defined as total TB-related costs accounting for more than 20% of annual household income. Result The median total cost of TB care was US$ 755 (Interquartile range 351–1,454). The costs were driven by direct non-medical costs (46.6%) and income loss (37.6%). Nutritional supplements accounted for 74.7% of direct non-medical costs. Half of the patients used savings, borrowed money or sold household assets to cope with TB. The proportion of unemployment more than doubled from 16.8% to 35.4% during the TB episode, especially among those working in the informal sector. Of all participants, 62.6% of TB-affected households faced catastrophic costs. This proportion was higher among households with DR-TB (86.7%) and TB-HIV coinfected patients (81.1%). Conclusion In Lao PDR, TB patients and their households faced a substantial financial burden due to TB, despite the availability of free TB services in public health facilities. As direct non-medical and indirect costs were major cost drivers, providing free TB services is not enough to ease this financial burden. Expansion of existing social protection schemes to accommodate the needs of TB patients is necessary.
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Affiliation(s)
| | - Takuya Yamanaka
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- * E-mail:
| | | | | | | | - Jacques Sebert
- National TB Programme, Ministry of Health, Vientiane, Lao PDR
| | - Kerri Viney
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
- Research School of Population Health, Australian National University, Canberra, Australia
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Moeko Nagai
- World Health Organization, Country Office, Vientiane, Lao PDR
| | - Vilath Seevisay
- World Health Organization, Country Office, Vientiane, Lao PDR
| | - Kiyohiko Izumi
- World Health Organization, Country Office, Vientiane, Lao PDR
| | - Fukushi Morishita
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Nobuyuki Nishikiori
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
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Rupani MP, Cattamanchi A, Shete PB, Vollmer WM, Basu S, Dave JD. Costs incurred by patients with drug-susceptible pulmonary tuberculosis in semi-urban and rural settings of Western India. Infect Dis Poverty 2020; 9:144. [PMID: 33076969 PMCID: PMC7574230 DOI: 10.1186/s40249-020-00760-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/30/2020] [Indexed: 11/19/2022] Open
Abstract
Background India reports the highest number of tuberculosis (TB) cases worldwide. Poverty has a dual impact as it increases the risk of TB and exposes the poor to economic hardship when they develop TB. Our objective was to estimate the costs incurred by patients with drug-susceptible TB in Bhavnagar (western India) using an adapted World Health Organization costing tool. Methods We conducted a descriptive cross-sectional study of adults, notified in the public sector and being treated for drug-susceptible pulmonary TB during January–June 2019, in six urban and three rural blocks of Bhavnagar region, Gujarat state, India. The direct and indirect TB-related costs, as well as patients’ coping strategies, were assessed for the overall care of TB till treatment completion. Catastrophic costs were defined as total costs > 20% of annual household income (excluding any amount received from cash transfer programs or borrowed). Median and interquartile range (IQR) was used to summarize patient costs. The median costs between any two groups were compared using the median test. The association between any two categorical variables was tested by the Pearson chi-squared test. All costs were described in US dollars (USD). During the study period, on average, one USD equalled 70 Indian Rupees. Results Of 458 patients included, 70% were male, 62% had no formal education, 71% lived in urban areas, and 96% completed TB treatment. The median (IQR) total costs were USD 8 (5–28), direct medical costs were USD 0 (0–0), direct non-medical costs were USD 3 (2–4) and indirect costs were USD 6 (3–13). Among direct non-medical costs, travel cost (median = USD 3, IQR: 2–4) to attend health facilities were the most prominent, whereas the indirect costs were mainly contributed by the patient’s loss of wages (median = USD 3, IQR: 0–6). Four percent of patients faced catastrophic costs, 11% borrowed money to cover costs and 7% lost their employment; the median working days lost to TB was 30 (IQR: 15–45). A majority (88%) of patients received a median USD 43 (IQR: 41–43) as part of a cash transfer program for TB patients. Conclusions Treatment completion was high and the costs incurred by TB patients were low in this setting. However, negative financial consequences occur even in low-cost settings. The role of universal cash transfer programs in such settings requires further study.
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Affiliation(s)
- Mihir P Rupani
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat 364001, India.
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco (UCSF), California, USA
| | - Priya B Shete
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco (UCSF), California, USA
| | - William M Vollmer
- Division of Biostatistics, Kaiser Permanente Center for Health Research, Portland, USA
| | - Sanjib Basu
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, USA
| | - Jigna D Dave
- Department of Respiratory Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Bhavnagar, Gujarat, India
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Muttamba W, Tumwebaze R, Mugenyi L, Batte C, Sekibira R, Nkolo A, Katamba A, Kasasa S, Majwala RK, Turyahabwe S, Mugabe F, Mugagga K, Lochoro P, Dejene S, Birabwa E, Marra C, Baena IG, Kirenga B. Households experiencing catastrophic costs due to tuberculosis in Uganda: magnitude and cost drivers. BMC Public Health 2020; 20:1409. [PMID: 32938411 PMCID: PMC7493412 DOI: 10.1186/s12889-020-09524-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 09/09/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) patients in Uganda incur large costs related to the illness, and while seeking and receiving health care. Such costs create access and adherence barriers which affect health outcomes and increase transmission of disease. The study ascertained the proportion of Ugandan TB affected households incurring catastrophic costs and the main cost drivers. METHODS A cross-sectional survey with retrospective data collection and projections was conducted in 2017. A total of 1178 drug resistant (DR) TB (44) and drug sensitive (DS) TB patients (1134), 2 weeks into intensive or continuation phase of treatment were consecutively enrolled across 67 randomly selected TB treatment facilities. RESULTS Of the 1178 respondents, 62.7% were male, 44.7% were aged 15-34 years and 55.5% were HIV positive. For each TB episode, patients on average incurred costs of USD 396 for a DS-TB episode and USD 3722 for a Multi drug resistant tuberculosis (MDR TB) episode. Up to 48.5% of households borrowed, used savings or sold assets to defray these costs. More than half (53.1%) of TB affected households experienced TB-related costs above 20% of their annual household expenditure, with the main cost drivers being non-medical expenditure such as travel, nutritional supplements and food. CONCLUSION Despite free health care in public health facilities, over half of Ugandan TB affected households experience catastrophic costs. Roll out of social protection interventions like TB assistance programs, insurance schemes, and enforcement of legislation related to social protection through multi-sectoral action plans with central NTP involvement would palliate these costs.
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Affiliation(s)
- Winters Muttamba
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Racheal Tumwebaze
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Levicatus Mugenyi
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Batte
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rogers Sekibira
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Abel Nkolo
- University Research Co, LLC (URC) & Center for Human Services (CHS), Kampala, Uganda
| | - Achilles Katamba
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Simon Kasasa
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert Kaos Majwala
- University Research Co, LLC (URC) & Center for Human Services (CHS), Kampala, Uganda
- National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda
| | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda
| | - Frank Mugabe
- National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda
| | | | | | | | | | - Claudio Marra
- National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda
| | | | - Bruce Kirenga
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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Wang Y, McNeil EB, Huang Z, Chen L, Lu X, Wang C, Chen H, Chongsuvivatwong V. Household financial burden among multidrug-resistant tuberculosis patients in Guizhou province, China: A cross-sectional study. Medicine (Baltimore) 2020; 99:e21023. [PMID: 32664107 PMCID: PMC7360282 DOI: 10.1097/md.0000000000021023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) threatens global public health. Poor access to health care due to financial hardship contributes to further transmission of the disease. The study aimed to:A cross-sectional study was conducted in 2 hospitals designated for MDR-TB from January to August 2018. Data were collected by interviewing eligible MDR-TB outpatients and reviewing the medical records. The magnitude of financial burden was documented by total cost and distribution of cost components. Catastrophic payments were measured by 2 indicators: catastrophic health expenditure (CHE) and catastrophic total costs (CTC), both of which were estimated by incidence and intensity. Their associated factors were determined using logistic regression models.Of 161 households affected by MDR-TB, the average total costs due to MDR-TB treatment in the first year was US$ 8266 and consisted of 72% direct medical costs, 5% direct non-medical costs and 23% indirect costs (income loss). Thirty seven percent of direct medical costs were covered by insurance. Overall, the incidence of CHE and CTC was 68.3% and 87.0%, respectively. Both incidence and intensity for the 2 defined catastrophic costs increased when a households income decreased. Five significant factors of catastrophic costs were low household income, absence of students in a family, hospital length of stay, male gender, and job/productivity loss.Households with MDR-TB patients shouldered a high financial burden which was mainly driven by direct medical costs and income loss in Guizhou. Greater catastrophic payments were associated with hospital length of stay and socioeconomic status, especially had a dose-response relationship with households income. Our findings suggest that financial and social protection of local policies for MDR-TB should be improved by preparing a uniform and comprehensive insurance package to cover sufficiently direct medical costs, and introducing social pro-poor assistance policies for risk families to protect them from financial hardship.
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Affiliation(s)
- Yun Wang
- Department of Health Service Management, School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou, China
| | - Edward B. McNeil
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Zhongfeng Huang
- Department of Tuberculosis, Guiyang Public Health Clinical Center, Guiyang
| | - Ling Chen
- Department of Respiratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi
| | - Xiaolong Lu
- Department of Health Service Management, School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou, China
| | - Chengqiong Wang
- Department of Respiratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi
| | - Huijuan Chen
- Department of Tuberculosis Prevention and Control, Guizhou Center for Disease Prevention and Control, Guiyang, Guizhou, China
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Yang T, Chen T, Che Y, Chen Q, Bo D. Factors associated with catastrophic total costs due to tuberculosis under a designated hospital service model: a cross-sectional study in China. BMC Public Health 2020; 20:1009. [PMID: 32586305 PMCID: PMC7318445 DOI: 10.1186/s12889-020-09136-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/17/2020] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Tianchi Yang
- Institute of Tuberculosis Prevention and Control, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, Zhejiang, China.
| | - Tong Chen
- Institute of Tuberculosis Prevention and Control, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, Zhejiang, China
| | - Yang Che
- Institute of Tuberculosis Prevention and Control, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, Zhejiang, China
| | - Qin Chen
- Division of Medical Insurance, Ningbo Huamei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Dingyi Bo
- Institute of Infectious Disease Control, Haishu District Center for Disease Control and Prevention, Ningbo, Zhejiang, China
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Su Y, Garcia Baena I, Harle AC, Crosby SW, Micah AE, Siroka A, Sahu M, Tsakalos G, Murray CJL, Floyd K, Dieleman JL. Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000-17: a financial modelling study. THE LANCET. INFECTIOUS DISEASES 2020; 20:929-942. [PMID: 32334658 PMCID: PMC7649746 DOI: 10.1016/s1473-3099(20)30124-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/31/2020] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Estimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000-17. METHODS We extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$. FINDINGS Total spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3·9% (95% CI 3·0 to 4·6), from $5·7 billion (5·2 to 6·5) in 2000 to $10·9 billion (10·3 to 11·8) in 2017. Government spending increased annually by 5·1% (4·4 to 5·7) between 2000 and 2017, and reached $6·9 billion (6·5 to 7·5) or 63·5% (59·2 to 66·8) of all tuberculosis spending in 2017. Of government spending, $5·8 billion (5·6 to 6·1) was spent on notified cases. Out-of-pocket spending decreased annually by 0·8% (-2·9 to 1·3), from $2·4 billion (1·9 to 3·1) in 2000 to $2·1 billion (1·6 to 2·7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54·6 million in 2000 to $1·1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85·3 million in 2000 to $576·2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73·7% (71·8-75·8) of tuberculosis spending in 2017. INTERPRETATION Despite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Yanfang Su
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | | | - Anton C Harle
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - Sawyer W Crosby
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - Angela E Micah
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | | | - Maitreyi Sahu
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - Golsum Tsakalos
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | | | - Katherine Floyd
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
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Stracker N, Hanrahan C, Mmolawa L, Nonyane B, Tampi R, Tucker A, West N, Lebina L, Martinson N, Dowdy D. Risk factors for catastrophic costs associated with tuberculosis in rural South Africa. Int J Tuberc Lung Dis 2020; 23:756-763. [PMID: 31315710 DOI: 10.5588/ijtld.18.0519] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
<sec> <title>SETTING</title> Fifty-five public clinics in northern South Africa. </sec> <sec> <title>OBJECTIVE</title> To estimate patient costs and identify the factors associated with catastrophic costs among individuals treated for tuberculosis (TB). </sec> <sec> <title>DESIGN</title> We performed cross-sectional interviews of consecutive patients at public clinics from October 2017 to January 2018. 'Catastrophic costs' were defined as costs totalling ≥20% of annual household income. For participants with no reported income, we considered scenarios where costs were considered non-catastrophic if 1) costs totalled <US$7.70 (ZAR100) or 2) a multidimensional poverty index was above a certain threshold. </sec> <sec> <title>RESULTS</title> Among 327 participants, the estimated mean TB episode costs were US$365 (95%CI 233-498): out-of-pocket costs comprised 58% of costs, wages lost due to health care-seeking represented 26%, and income reduction accounted for 16% of costs. Ninety (28%) participants experienced catastrophic costs, which were associated with clinic travel times of 60-90 min (adjusted prevalence ratio [aPR] 1.7, 95%CI 0.9-3.1), unemployment (aPR 2.0, 95%CI 1.0-4.0) and having fewer household members (aPR 0.6, 95%CI 0.3-1.0). </sec> <sec> <title>CONCLUSIONS</title> In rural South Africa, catastrophic costs from TB are common and associated with distance to clinics, unemployment, and household size. These findings can help tailor social protection programs and enhance service delivery to patients at greatest risk of experiencing financial hardship. </sec>.
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Affiliation(s)
| | | | - L Mmolawa
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - B Nonyane
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - R Tampi
- Departments of Epidemiology and
| | | | - N West
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - L Lebina
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - N Martinson
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa, Johns Hopkins University, Center for Tuberculosis Research, Baltimore, Maryland, USA
| | - D Dowdy
- Departments of Epidemiology and, International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Johns Hopkins University, Center for Tuberculosis Research, Baltimore, Maryland, USA
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Ayiraveetil R, Sarkar S, Chinnakali P, Jeyashree K, Vijayageetha M, Thekkur P, Lakshminarayanan S, Knudsen S, Hochberg NS, Horsburgh CR, Ellner J, Roy G. Household food insecurity among patients with pulmonary tuberculosis and its associated factors in South India: a cross-sectional analysis. BMJ Open 2020; 10:e033798. [PMID: 32114470 PMCID: PMC7050349 DOI: 10.1136/bmjopen-2019-033798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Food insecurity is 'the limited or uncertain availability of nutritionally adequate, safe foods or inability to acquire foods in socially acceptable ways'. Majority of tuberculosis (TB) cases of resource-poor settings experience food insecurity, which impacts treatment adherence and outcomes. We aimed to determine level of household food insecurity (HFI) and its associated factors in patients with pulmonary TB. DESIGN This is a cross-sectional analysis of data from an ongoing cohort study. SETTING National Tuberculosis Programme (NTP) in three districts of South India. PARTICIPANTS All newly diagnosed pulmonary TB cases of the cohort enrolled in the NTP at the Designated Microscopy Centres (DMCs) and Primary Health Centres (PHCs) from October 2015 to October 2018. PRIMARY OUTCOME MEASURES The proportion of baseline HFI assessed using a validated HFI Access Scale was summarised as percentage with 95% CI. Possible association of sociodemographic, morbidity and behavioural characteristics with HFI was assessed using χ2 test, and unadjusted prevalence ratios with 95% CI were calculated. The characteristics with values of p<0.2 in the univariate model were included in the multivariable generalised linear model (binomial function, log link) to derive adjusted prevalence ratios (aPRs) with 95% CI. RESULT Of a total of 765 patients, 261 had HFI and the proportion was 34.1% (95% CI 30.8% to 37.6%). Mild, moderate and severe food insecurity was found in 17 (2.2%), 67 (8.8%) and 177 (23.1%) TB cases, respectively. Patients with TB who had monthly family income less than rupees 3000 (aPR 2.0; 95% CI 1.3 to 3.0), Karnofsky Score of 60 or less (aPR 1.5; 95% CI 1.1 to 1.9) and those who were employed (aPR 1.4; 95% CI 1.0 to 2.0) were independently associated with HFI. CONCLUSIONS A high level of food insecurity was seen in households with TB cases. Additional food or cash assistance for this subgroup might improve food insecurity and thereby nutritional status.
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Affiliation(s)
- Reshma Ayiraveetil
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sonali Sarkar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Palanivel Chinnakali
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kathiresan Jeyashree
- Department of Community Medicine, Velammal Medical College, Madurai, Tamilnadu, India
| | - Mathavaswami Vijayageetha
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Pruthu Thekkur
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France
- The Union South-East Asia Office, New Delhi, India
| | - Subitha Lakshminarayanan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Selby Knudsen
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Massachusetts, United States
| | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Massachusetts, United States
- Department of Epidemiology, Boston University School of Public Health, Massachusetts, United States
| | - C Robert Horsburgh
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Massachusetts, United States
- Department of Epidemiology, Boston University School of Public Health, Massachusetts, United States
- Department of Global Health, Boston University School of Public Health, Massachusetts, United States
| | - Jerrold Ellner
- Department of Medicine, Rutgers University, New Jersey, United States
| | - Gautam Roy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Vo LNQ, Codlin AJ, Forse RJ, Nguyen HT, Vu TN, Van Truong V, Do GC, Nguyen LH, Le GT, Caws M. Tuberculosis among economic migrants: a cross-sectional study of the risk of poor treatment outcomes and impact of a treatment adherence intervention among temporary residents in an urban district in Ho Chi Minh City, Viet Nam. BMC Infect Dis 2020; 20:134. [PMID: 32050913 PMCID: PMC7017549 DOI: 10.1186/s12879-020-4865-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a major cause of avoidable deaths. Economic migrants represent a vulnerable population due to their exposure to medical and social risk factors. These factors expose them to higher risks for TB incidence and poor treatment outcomes. METHODS This cross-sectional study evaluated WHO-defined TB treatment outcomes among economic migrants in an urban district of Ho Chi Minh City, Viet Nam. We measured the association of a patient's government-defined residency status with treatment success and loss to follow-up categories at baseline and performed a comparative interrupted time series (ITS) analysis to assess the impact of community-based adherence support on treatment outcomes. Key measures of interest of the ITS were the differences in step change (β6) and post-intervention trend (β7). RESULTS Short-term, inter-province migrants experienced lower treatment success (aRR = 0.95 [95% CI: 0.92-0.99], p = 0.010) and higher loss to follow-up (aOR = 1.98 [95% CI: 1.44-2.72], p < 0.001) than permanent residents. Intra-province migrants were similarly more likely to be lost to follow-up (aOR = 1.86 [95% CI: 1.03-3.36], p = 0.041). There was evidence that patients > 55 years of age (aRR = 0.93 [95% CI: 0.89-0.96], p < 0.001), relapse patients (aRR = 0.89 [95% CI: 0.84-0.94], p < 0.001), and retreatment patients (aRR = 0.62 [95% CI: 0.52-0.75], p < 0.001) had lower treatment success rates. TB/HIV co-infection was also associated with lower treatment success (aRR = 0.77 [95% CI: 0.73-0.82], p < 0.001) and higher loss to follow-up (aOR = 2.18 [95% CI: 1.55-3.06], p < 0.001). The provision of treatment adherence support increased treatment success (IRR(β6) = 1.07 [95% CI: 1.00, 1.15], p = 0.041) and reduced loss to follow-up (IRR(β6) = 0.17 [95% CI: 0.04, 0.69], p = 0.013) in the intervention districts. Loss to follow-up continued to decline throughout the post-implementation period (IRR(β7) = 0.90 [95% CI: 0.83, 0.98], p = 0.019). CONCLUSIONS Economic migrants, particularly those crossing provincial borders, have higher risk of poor treatment outcomes and should be prioritized for tailored adherence support. In light of accelerating urbanization in many regions of Asia, implementation trials are needed to inform evidence-based design of strategies for this vulnerable population.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam. .,Interactive Research and Development, Ho Chi Minh City, Viet Nam.
| | - Andrew James Codlin
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam
| | | | - Thanh Nguyen Vu
- Ho Chi Minh City Public Health Association, Ho Chi Minh City, Viet Nam
| | | | - Giang Chau Do
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | | | - Giang Truong Le
- Ho Chi Minh City Public Health Association, Ho Chi Minh City, Viet Nam
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, UK.,Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
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42
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Nirgude AS, Kumar AMV, Collins T, Naik PR, Parmar M, Tao L, Akshaya KM, Raghuveer P, Yatnatti SK, Nagendra N, Nagaraja SB, Habeena S, Mn B, Rao R, Shastri S. 'I am on treatment since 5 months but I have not received any money': coverage, delays and implementation challenges of 'Direct Benefit Transfer' for tuberculosis patients - a mixed-methods study from South India. Glob Health Action 2019; 12:1633725. [PMID: 31328678 PMCID: PMC6713952 DOI: 10.1080/16549716.2019.1633725] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: In March 2018, the Government of India launched a direct benefit transfer (DBT) scheme to provide nutritional support for all tuberculosis (TB) patients in line with END TB strategy. Here, the money (@INR 500 [~8 USD] per month) is deposited electronically into the bank accounts of beneficiaries. To avail the benefit, patients are to be notified in NIKSHAY (web-based notification portal of India’s national TB programme) and provide bank account details. Once these details are entered into NIKSHAY, checked and approved by the TB programme officials, it is sent to the public financial management system (PFMS) portal for further processing and payment. Objectives: To assess the coverage and implementation barriers of DBT among TB patients notified during April–June 2018 and residing in Dakshina Kannada, a district in South India. Methods: This was a convergent mixed-methods study involving cohort analysis of patient data from NIKSHAY and thematic analysis of in-depth interviews of providers and patients. Results: Of 417 patients, 208 (49.9%) received approvals for payment by PFMS and 119 (28.7%) got paid by 1 December 2018 (censor date). Reasons for not receiving DBT included (i) not having a bank account especially among migrant labourers in urban areas, (ii) refusal to avail DBT by rich patients and those with confidentiality concerns, (iii) lack of knowledge and (iv) perception that money was too little to meet the needs. The median (IQR) delay from diagnosis to payment was 101 (67–173) days. Delays were related to the complexity of processes requiring multiple layers of approval and paper-based documentation which overburdened the staff, bulk processing once-a-month and technological challenges (poor connectivity and issues related to NIKSHAY and PFMS portals). Conclusion: DBT coverage was low and there were substantial delays. Implementation barriers need to be addressed urgently to improve uptake and efficiency. The TB programme has begun to take action.
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Affiliation(s)
- Abhay Subhashrao Nirgude
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India
| | - Ajay M V Kumar
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India.,b Department of Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,c Department of Research, The Union South-East Asia Office , New Delhi , India
| | - Timire Collins
- d Center for Operations Research, International Union Against Tuberculosis and LungDisease , Harare , Zimbabwe
| | - Poonam Ramesh Naik
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India
| | - Malik Parmar
- e Communicable Disease Section (Tuberculosis), WHO Country Office for India , New Delhi , India
| | - Li Tao
- f National Center for Tuberculosis Control and Prevention, China CDC , Beijing , China
| | - Kibballi Madhukeshwar Akshaya
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India
| | - Pracheth Raghuveer
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India
| | - Santosh K Yatnatti
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India
| | - Navya Nagendra
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India
| | - Sharath B Nagaraja
- g Department of Community Medicine, ESIC Medical College and PGIMSR , Bengaluru , India
| | - Shaira Habeena
- a Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University) , Mangaluru , India
| | - Badarudeen Mn
- h Health and Family Welfare Department , Mangaluru , India
| | - Ramkrishna Rao
- h Health and Family Welfare Department , Mangaluru , India
| | - Suresh Shastri
- i Karnataka State AIDS Prevention Society and State Tuberculosis Cell , Bangalore , Karnataka , India
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43
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Gurung SC, Dixit K, Rai B, Caws M, Paudel PR, Dhital R, Acharya S, Budhathoki G, Malla D, Levy JW, van Rest J, Lönnroth K, Viney K, Ramsay A, Wingfield T, Basnyat B, Thapa A, Squire B, Wang D, Mishra G, Shah K, Shrestha A, de Siqueira-Filha NT. The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal. Infect Dis Poverty 2019; 8:99. [PMID: 31791412 PMCID: PMC6889665 DOI: 10.1186/s40249-019-0603-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/23/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) End TB Strategy has established a milestone to reduce the number of tuberculosis (TB)- affected households facing catastrophic costs to zero by 2020. The role of active case finding (ACF) in reducing patient costs has not been determined globally. This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding (PCF), and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal. METHODS The study was conducted in two districts of Nepal: Bardiya and Pyuthan (Province No. 5) between June and August 2018. One hundred patients were included in this study in a 1:1 ratio (PCF: ACF, 25 consecutive ACF and 25 consecutive PCF patients in each district). The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs. Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20% of their annual household income. The intensity of catastrophic costs was calculated using the positive overshoot method. The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs. Meanwhile, the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis. RESULTS Ninety-nine patients were interviewed (50 ACF and 49 PCF). Patients diagnosed through ACF incurred lower costs during the pre-treatment period (direct medical: USD 14 vs USD 32, P = 0.001; direct non-medical: USD 3 vs USD 10, P = 0.004; indirect, time loss: USD 4 vs USD 13, P < 0.001). The cost of the pre-treatment and intensive phases combined was also lower for direct medical (USD 15 vs USD 34, P = 0.002) and non-medical (USD 30 vs USD 54, P = 0.022) costs among ACF patients. The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds. A lower intensity of catastrophic costs was also documented for ACF patients, although the difference was not statistically significant. CONCLUSIONS ACF can reduce patient-incurred costs substantially, contributing to the End TB Strategy target. Other synergistic policies, such as social protection, will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.
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Affiliation(s)
| | | | - Bhola Rai
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Maxine Caws
- Birat Nepal Medical Trust, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | | | | | - Jens W. Levy
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Job van Rest
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Knut Lönnroth
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Kerri Viney
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, Australian National University, Canberra, Australia
| | | | - Tom Wingfield
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Anil Thapa
- National Tuberculosis Centre, Bhaktapur, Nepal
| | - Bertie Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Gokul Mishra
- Birat Nepal Medical Trust, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Noemia Teixeira de Siqueira-Filha
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Institute for Health Technology Assessment, Porto Alegre, Brazil
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44
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Hoa NB, Nhung NV. National tuberculosis patients cost survey: research findings lead to change in policy and practice, Viet Nam. Public Health Action 2019; 9:50-52. [PMID: 31417852 DOI: 10.5588/pha.18.0082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/18/2019] [Indexed: 11/10/2022] Open
Abstract
In 2016, the Viet Nam National Tuberculosis Programme (NTP) conducted the first national TB patients cost survey to identify the main cost drivers to help guide cost mitigation policies and reduce financial barriers to the treatment of TB patients. The survey findings were widely disseminated and the NTP defined a roadmap. The major components of the roadmap included 1) advocating for patients to be covered by social health insurance; 2) creating a charity fund for TB patients; 3) strengthening the collaboration between the Ministry of Health and Ministry of Labour and Social Affairs; and 4) advocating for donor support. The first national TB patients cost survey has shown that a high proportion of TB patients incurred costs that were classed as 'catastrophic'. The survey findings led to policy changes and new practices in Viet Nam.
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Affiliation(s)
- N B Hoa
- National Tuberculosis Programme Viet Nam, Hanoi, Viet Nam.,Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France
| | - N V Nhung
- National Tuberculosis Programme Viet Nam, Hanoi, Viet Nam.,Hanoi Medical University, Hanoi, Viet Nam
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45
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Xu CH, Jeyashree K, Shewade HD, Xia YY, Wang LX, Liu Y, Zhang H, Wang L. Inequity in catastrophic costs among tuberculosis-affected households in China. Infect Dis Poverty 2019; 8:46. [PMID: 31215476 PMCID: PMC6582572 DOI: 10.1186/s40249-019-0564-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are limited nationally representative studies globally in the post-2015 END tuberculosis (TB) era regarding wealth related inequity in the distribution of catastrophic costs due to TB care. Under the Chinese national tuberculosis programme setting, we aimed to assess extent of equity in distribution of total TB care costs (pre-treatment, treatment and overall) and costs as a proportion of annual household income (AHI), and describe and compare equity in distribution of catastrophic costs (pre-treatment, treatment and overall) across population sub-groups. METHODS Analytical cross-sectional study using data from national TB patient cost survey carried out in 22 counties from six provinces in China in 2017. Drug-susceptible pulmonary TB registered under programme, who had received at least 2 weeks of intensive phase therapy were included. Equity was depicted using concentration curves and concentration indices were compared using dominance test. RESULTS Of 1147 patients, the median cost of pre-treatment, treatment and overall care, were USD 283.5, USD 413.1 and USD 965.5, respectively. Richer quintiles incurred significantly higher pre-treatment and treatment costs compared to poorer quintiles. The distribution of costs as a proportion of AHI and catastrophic costs were significantly pro-poor overall as well as during pre-treatment and treatment phase. All the concentration curves for catastrophic costs (due to pre-treatment, treatment and overall care) stratified by region (east, middle and west), area of residence (urban, rural) and type of insurance (new rural co-operative medical system [NCMS], non-NCMS) also exhibited a pro-poor pattern with statistically significant (P < 0.01) concentration indices. The pro-poor distribution of the catastrophic costs due to TB treatment was significantly more inequitable among rural, compared to urban patients, and NCMS compared to non-NCMS beneficiaries. CONCLUSIONS There is inequity in the distribution of catastrophic costs due to TB care. Universal health coverage, social protection strategies complemented by quality TB care is vital to reduce inequitable distribution of catastrophic costs due to TB care in China.
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Affiliation(s)
- Cai-Hong Xu
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Kathiresan Jeyashree
- Velammal Medical College Hospital and Research Institute, Madurai, 625009, India
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, 110016, India
- International Union Against Tuberculosis and Lung Disease (The Union), 75006, Paris, France
- Karuna Trust, Bengaluru, 560041, India
| | - Yin-Yin Xia
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Li-Xia Wang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Yan Liu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China.
| | - Li Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.
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46
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Viney K, Islam T, Hoa NB, Morishita F, Lönnroth K. The Financial Burden of Tuberculosis for Patients in the Western-Pacific Region. Trop Med Infect Dis 2019; 4:tropicalmed4020094. [PMID: 31212985 PMCID: PMC6631110 DOI: 10.3390/tropicalmed4020094] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 01/06/2023] Open
Abstract
The End Tuberculosis (TB) Strategy has the ambitious goal of ending the global TB epidemic by the year 2030, which is aligned to the Sustainable Development Goals. One of three high level indicators of the Strategy is the “catastrophic costs” indicator, which aims to determine the proportion of TB-affected households that incur TB-care related costs equivalent to 20% or more of their annual household income. The target is that zero percentage of TB-affected households will incur catastrophic costs related to TB care by the year 2020. In the Western Pacific Region of the World Health Organization, it is a priority to determine the financial burden of TB and then act to mitigate it. To date, eight countries in the Region have conducted nationally representative TB patient cost surveys to determine the costs of TB care. The results from four countries that have completed these surveys (i.e., Fiji, Mongolia, the Philippines, and Vietnam) indicate that between 35% and 70% of TB patients face catastrophic costs related to their TB care. With these results in mind, significant additional efforts are needed to ensure financial risk protection for TB patients, expand Universal Health Coverage, and improve access to social protection interventions. A multi-sectoral approach is necessary to achieve this ambitious goal by the year 2020.
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Affiliation(s)
- Kerri Viney
- Centre for TB Research, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
- Research School of Population Health, Australian National University, Canberra 2600, Australia.
| | - Tauhidul Islam
- End TB and Leprosy Unit, World Health Organization Regional Office for the Western Pacific, 1000 Manila, Philippines.
| | - Nguyen Binh Hoa
- Vietnam National TB Programme, Ministry of Health, Hanoi 124302, Vietnam.
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, 75006 Paris, France.
| | - Fukushi Morishita
- End TB and Leprosy Unit, World Health Organization Regional Office for the Western Pacific, 1000 Manila, Philippines.
| | - Knut Lönnroth
- Centre for TB Research, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
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Watts K. Is Australia Neglecting the Local Topography When It Comes to Catastrophic Costs and Ending Tuberculosis? Trop Med Infect Dis 2018; 3:tropicalmed3040126. [PMID: 30572647 PMCID: PMC6306854 DOI: 10.3390/tropicalmed3040126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 11/16/2022] Open
Abstract
Efforts to eliminate tuberculosis as a public health problem require reductions in mortality, incidence, and the eradication of associated catastrophic costs; however, the question of catastrophic costs is often neglected, particularly in the context of low-incidence settings like Australia. This study reviews the financial support provided to those identified as in need, and in receipt, of economic aid from the Victorian Tuberculosis Program. The study design used Epstein's clinical data mining framework to produce descriptive statistics which were supplemented by clinical collaboration. A consistent one-third of those receiving care from the Program due to a notification of active tuberculosis received emergency financial relief over the study period. Overwhelmingly, funds were used to relieve financial distress, and each year approximately one-third of the expenditure was used to support 2% of those people notified as affected by tuberculosis (or 7⁻9% of those in receipt of funds). Many of this 2% experienced income loss and expenditure that may be considered catastrophic. Further investigation is needed to better define and understand the nature of catastrophic costs in the context of universal health care and existing low tuberculosis incidence.
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Affiliation(s)
- Krista Watts
- Victorian Tuberculosis Program, Melbourne Health, Parkville 3050, Australia.
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