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Abdullahi LH, Oketch S, Komen H, Mbithi I, Millington K, Mulupi S, Chakaya J, Zulu EM. Gendered gaps to tuberculosis prevention and care in Kenya: a political economy analysis study. BMJ Open 2024; 14:e077989. [PMID: 38569714 DOI: 10.1136/bmjopen-2023-077989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a public health concern in Kenya despite the massive global efforts towards ending TB. The impediments to TB prevention and care efforts include poor health systems, resource limitations and other sociopolitical contexts that inform policy and implementation. Notably, TB cases are much higher in men than women. Therefore, the political economy analysis (PEA) study provides in-depth contexts and understanding of the gender gaps to access and successful treatment for TB infection. DESIGN PEA adopts a qualitative, in-depth approach through key informant interviews (KII) and documentary analysis. SETTING AND PARTICIPANTS The KIIs were distributed among government entities, academia, non-state actors and community TB groups from Kenya. RESULTS The themes identified were mapped onto the applied PEA analysis framework domains. The contextual and institutional issues included gender concerns related to the disconnect between TB policies and gender inclusion aspects, such as low prioritisation for TB programmes, limited use of evidence to inform decisions and poor health system structures. The broad barriers influencing the social contexts for TB programmes were social stigma and cultural norms such as traditional interventions that negatively impact health-seeking behaviours. The themes around the economic situation were poverty and unemployment, food insecurity and malnutrition. The political context centred around the systemic and governance gaps in the health system from the national and devolved health functions. CONCLUSION Broad contextual factors identified from the PEA widen the disparity in targeted gender efforts toward men. Following the development of effective TB policies and strategies, it is essential to have well-planned gendered responsive interventions with a clear implementation plan and monitoring system to enhance access to TB prevention and care.
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Affiliation(s)
- Leila H Abdullahi
- Research Department, African Institute for Development Policy, Nairobi, Kenya
| | - Sandra Oketch
- African Institute for Development Policy (AFIDEP), Nairobi, Kenya
| | - Henry Komen
- African Institute for Development Policy (AFIDEP), Nairobi, Kenya
| | | | | | | | | | - Eliya M Zulu
- African Institute for Development Policy, Nairobi, Kenya
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kerama C, Horne D, Ong’ang’o J, Anzala O. Rethinking the syndemic of tuberculosis and dysglycaemia: a Kenyan perspective on dysglycaemia as a neglected risk factor for tuberculosis. Bull Natl Res Cent 2023; 47:53. [PMID: 37073382 PMCID: PMC10098226 DOI: 10.1186/s42269-023-01029-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/09/2023] [Indexed: 05/03/2023]
Abstract
Background The END TB 2035 goal has a long way to go in low-income and low/middle-income countries (LICs and LMICs) from the perspective of a non-communicable disease (NCD) control interaction with tuberculosis (TB). The World Health Organization has identified diabetes as a determinant for, and an important yet neglected risk factor for tuberculosis. National guidelines have dictated testing time points, but these tend to be at an isolated time point rather than over a period of time. This article aims to give perspective on the syndemic interaction of tuberculosis and dysglycaemia and how the gaps in addressing the two may hamper progress towards END TB 2035. Main text Glycated haemoglobin (HbA1C) has a strong predictive association with the progression to subsequent diabetes. Therefore, screening using this measure could be a good way to screen at TB initiation therapy, in lieu of using the random blood sugar or fasting plasma glucose only. HbA1C has an observed gradient with mortality risk making it an informative predictor of outcomes. Determining the progression of dysglycaemia from diagnosis to end of treatment and shortly after may offer information on the best time point to screen and follow-up. Despite TB and Human Immunodeficiency Virus (HIV) disease care being free, hidden costs remain. These costs are additive if there is accompanying dysglycaemia. Regardless of receiving TB treatment, it is estimated that almost half of persons affected by pulmonary TB develop post-TB lung disease (PTLD) as an outcome and the contribution of dysglycaemia is not well described. Conclusions Establishing costs of treating TB with diabetes/prediabetes alone and in the additional context of HIV co-infection will inform policy makers on what it takes, financially, to treat these patients and subsidize dysglycaemia care. In Kenya, cardiovascular disease is only rivalled by infectious disease as a cause of mortality, and diabetes is a well-described risk factor for cardiac disease. In poor countries, communicable diseases are responsible for majority of the mortality burden, but societal shifts and rural-urban migration may have contributed to the observed increase of NCDs.
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Affiliation(s)
- Cheryl Kerama
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute (CRDR-KEMRI), Past Government Chemist, Opposite Diabetes Clinic, Nairobi, Kenya
- Division of Medical Microbiology and Immunology, Kenya AIDS Vaccine Initiative-Institute for Clinical Research (KAVI-ICR), Nairobi, Kenya
| | - David Horne
- Division of Pulmonary and Critical Care and Sleep Medicine, University of Washington, Seattle, WA USA
| | - Jane Ong’ang’o
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute (CRDR-KEMRI), Past Government Chemist, Opposite Diabetes Clinic, Nairobi, Kenya
| | - Omu Anzala
- Division of Medical Microbiology and Immunology, Kenya AIDS Vaccine Initiative-Institute for Clinical Research (KAVI-ICR), Nairobi, Kenya
- School of Medicine, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
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Kumar D, Prinja S. Costing of services under National Tuberculosis Elimination Program at public health facilities of northern India. Indian J Tuberc 2023; 70:232-238. [PMID: 37100581 DOI: 10.1016/j.ijtb.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND Costing of resources helps to measure financial implications and effective utilization of resources of national programs. As there is limited evidence about cost per service, current study was done to assess the cost of services under National Tuberculosis Elimination Program (NTEP) at Community Health Centres (CHCs) and Primary Health Centres (PHCs) of northern state of India. MATERIAL AND METHODS Cross-sectional study carried out in two districts and from each district eight CHCs and PHCs were randomly selected. RESULTS Mean annual cost of providing NTEP services at CHCs and PHCs were US$5243.1 (95%CI: 3008.0-7225.4) and US$1031.9 (95%CI: 669.1-1447.1) respectively. Across both centres human resource contributes to the most (CHC: 72.9%; PHC: 85.9%). One way sensitivity analysis was carried out for all health facilities and observed that human resource cost influences most cost per treated case by providing services under NTEP. Although relatively very less but cost of drugs also influences cost per treatment. CONCLUSION Cost of delivering services was high for CHCs as compared to PHCs. At both types of health facilities, human resource contributes the most to cost of delivering services under the program.
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Affiliation(s)
- Dinesh Kumar
- Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, 176001, India.
| | - Shankar Prinja
- School of Public Health and Community Medicine, Post Graduate Institute of Medical Education and Research. Chandigarh, 160012, India.
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Satyanarayana S, Pretorius C, Kanchar A, Garcia Baena I, Den Boon S, Miller C, Zignol M, Kasaeva T, Falzon D. Scaling Up TB Screening and TB Preventive Treatment Globally: Key Actions and Healthcare Service Costs. Trop Med Infect Dis 2023; 8:214. [PMID: 37104339 PMCID: PMC10144108 DOI: 10.3390/tropicalmed8040214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023] Open
Abstract
The 2018 United Nations High-Level Meeting on Tuberculosis (UNHLM) set targets for case detection and TB preventive treatment (TPT) by 2022. However, by the start of 2022, about 13.7 million TB patients still needed to be detected and treated, and 21.8 million household contacts needed to be given TPT globally. To inform future target setting, we examined how the 2018 UNHLM targets could have been achieved using WHO-recommended interventions for TB detection and TPT in 33 high-TB burden countries in the final year of the period covered by the UNHLM targets. We used OneHealth-TIME model outputs combined with the unit cost of interventions to derive the total costs of health services. Our model estimated that, in order to achieve UNHLM targets, >45 million people attending health facilities with symptoms would have needed to be evaluated for TB. An additional 23.1 million people with HIV, 19.4 million household TB contacts, and 303 million individuals from high-risk groups would have required systematic screening for TB. The estimated total costs amounted to ~USD 6.7 billion, of which ~15% was required for passive case finding, ~10% for screening people with HIV, ~4% for screening household contacts, ~65% for screening other risk groups, and ~6% for providing TPT to household contacts. Significant mobilization of additional domestic and international investments in TB healthcare services will be needed to reach such targets in the future.
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Affiliation(s)
- Srinath Satyanarayana
- Centre for Operational Research, International Union against Tuberculosis and Lung Disease (The Union), New Delhi 110016, India
| | - Carel Pretorius
- Centre for Modelling and Analysis, Avenir Health, Glastonbury, CT 06033, USA
| | - Avinash Kanchar
- Global TB Programme (GTB), World Health Organization, 1211 Geneva, Switzerland
| | - Ines Garcia Baena
- Global TB Programme (GTB), World Health Organization, 1211 Geneva, Switzerland
| | - Saskia Den Boon
- Global TB Programme (GTB), World Health Organization, 1211 Geneva, Switzerland
| | - Cecily Miller
- Global TB Programme (GTB), World Health Organization, 1211 Geneva, Switzerland
| | - Matteo Zignol
- Global TB Programme (GTB), World Health Organization, 1211 Geneva, Switzerland
| | - Tereza Kasaeva
- Global TB Programme (GTB), World Health Organization, 1211 Geneva, Switzerland
| | - Dennis Falzon
- Global TB Programme (GTB), World Health Organization, 1211 Geneva, Switzerland
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Ryckman TS, Dowdy DW, Kendall EA. Infectious and clinical tuberculosis trajectories: Bayesian modeling with case finding implications. Proc Natl Acad Sci U S A 2022; 119:e2211045119. [PMID: 36534797 DOI: 10.1073/pnas.2211045119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The importance of finding people with undiagnosed tuberculosis (TB) hinges on their future disease trajectories. Assays for systematic screening should be optimized to find those whose TB will contribute most to future transmission or morbidity. In this study, we constructed a mathematical model that tracks the future trajectories of individuals with TB at a cross-sectional timepoint ("baseline"), classifying them by bacterial burden (smear positive/negative) and symptom status (symptomatic/subclinical). We used Bayesian methods to calibrate this model to targets derived from historical survival data and notification, mortality, and prevalence data from five countries. We combined resulting disease trajectories with evidence on infectiousness to estimate each baseline TB state's contribution to future transmission. For a person with smear-negative subclinical TB at baseline, the expected future duration of disease was short (mean 4.8 [95% uncertainty interval 3.3 to 8.4] mo); nearly all disease courses ended in spontaneous resolution, not treatment. In contrast, people with baseline smear-positive subclinical TB had longer undiagnosed disease durations (15.9 [11.1 to 23.5] mo); nearly all eventually developed symptoms and ended in treatment or death. Despite accounting for only 11 to 19% of prevalent disease, smear-positive subclinical TB accounted for 35 to 51% of future transmission-a greater contribution than symptomatic or smear-negative TB. Subclinical TB with a high bacterial burden accounts for a disproportionate share of future transmission. Priority should be given to developing inexpensive, easy-to-use assays for screening both symptomatic and asymptomatic individuals at scale-akin to rapid antigen tests for other diseases-even if these assays lack the sensitivity to detect paucibacillary disease.
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Sweeney S, Laurence YV, Cunnama L, Gomez GB, Garcia-Baena I, Bhide P, Capeding TJ, Chatterjee S, Chikovani I, Eyob H, Kairu A, Terefe MM, Shengelia N, Toshniwal M, Saadi N, Bergren E, Vassall A. Cost of TB services: approach and summary findings of a multi-country study (Value TB). Int J Tuberc Lung Dis 2022; 26:1006-1015. [PMID: 36281042 PMCID: PMC9621303 DOI: 10.5588/ijtld.22.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: There are currently large gaps in unit cost data for TB, and substantial variation in the quality and methods of unit cost estimates. Uncertainties remain about sample size, range and comprehensiveness of cost data collection for different purposes. We present the methods and results of a project implemented in Kenya, Ethiopia, India, The Philippines and Georgia to estimate unit costs of TB services, focusing on findings most relevant to these remaining methodological challenges.METHODS: We estimated financial and economic unit costs, in close collaboration with national TB programmes. Gold standard methods included both top-down and bottom-up approaches to resource use measurement. Costs are presented in 2018 USD and local currency unit.RESULTS: Cost drivers of outputs varied by service and across countries, as did levels of capacity inefficiency. There was substantial variation in unit cost estimates for some interventions and high overhead costs were observed. Estimates were subject to sampling uncertainty, and some data gaps remain.CONCLUSION: This paper describes detailed methods for the largest TB costing effort to date, to inform prioritisation and planning for TB services. This study provides a strong baseline and some cost estimates may be extrapolated from this data; however, regular further studies of similar quality are needed to add estimates for remaining gaps, or to add new or changing services and interventions. Further research is needed on the best approach to extrapolation of cost data. Costing studies are best implemented as partnerships with policy makers to generate a community of mutual learning and capacity development.
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Affiliation(s)
- S Sweeney
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Y V Laurence
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - L Cunnama
- University of Cape Town, Cape Town, South Africa
| | - G B Gomez
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK, Global Access, International Aids Vaccine Initiative, Amsterdam, The Netherlands
| | | | - P Bhide
- The George Institute for Global Health, New Delhi, India
| | - T J Capeding
- University of the Philippines Manila, Manila, The Philippines
| | - S Chatterjee
- The George Institute for Global Health, New Delhi, India
| | - I Chikovani
- Curatio International Foundation, Tbilisi, Georgia
| | - H Eyob
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - A Kairu
- Health Economics Research Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - M M Terefe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - N Shengelia
- Curatio International Foundation, Tbilisi, Georgia
| | | | - N Saadi
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK, University of Oslo, Oslo, Norway
| | - E Bergren
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A Vassall
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
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