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Reaching the poor : challenges for TB programmes in the Western Pacific Region

31 décembre 2004 Organisation mondiale de la santé

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reaching the POOR CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

World Health Organization Regional Office for the Western Pacific

Acknowledgements: The main contributors to this document are: Sarah Coll-Black, Pieter Van Maaren, Dongil Ahn and Takeshi Kasai, Stop TB Unit, and Anjana Bhushan, Health Systems Unit of the World Health Organization Regional Office for the Western Pacific. The team gratefully acknowledges the work on TB and poverty commissioned by the Stop TB Partnership in Geneva, of which WHO Headquarters serves as Secretariat. In particular, this document builds on Tuberculosis, poverty and inequity: a review of the literature and discussion of issues (2002), by Christy Hanson and A systematic analysis of TB and poverty (2003), by Bertha Nhlema, Julia Kemp, Ger Steenbergen, Sally Theobald, Shenglan Tang, and Bertel Squire, both commissioned by the Stop TB Partnership. Photograph credits: pp. 11, FAO/19649/G. Bizzarri; pp. 2, FAO/19665/G. Bizzari; cover, FAO/19669/G. Bizzarri; pp. 22, FAO/19717/G. Bizzarri; pp. 3, FAO/15685/P . Gigli; pp. 19, FAO/19197/P . Johnson; pp. 15, International Labour Organization/Deloche P .; pp. 25, 34, International Labour Organization/Rain N.; pp. 1, 6, 13, 14, WHO/WPRO; pp. i, www.photos.com.

WHO Library Cataloguing in Publication Data Reaching the poor: challenges for the TB programmes in the Western Pacific Region 1. Tuberculosis. 2. Poverty. 3. Directly observed therapy. ISBN 92 9061 093 X (NLM Classification: WF 200)

© World Health Organization 2004 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them - whether for sale or for noncommercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P .O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who.int

Poverty can influence the way the poor perceive their illness, their health seeking behaviour, when and where they access diagnosis and proper treatment, the quality of care they receive and whether they achieve a successful outcome.

TABLE OF CONTENTS

iii

Table of Contents List of Abbreviations • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • iv Foreword • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • v Executive Summary • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • vi 1 2 2.1 2.2 3 3.1 3.2 3.3 3.4 4 4.1 4.2 4.3 4.4 5 5.1 5.2 5.3 6 6.1 6.2 6.3 6.4 What is poverty? •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

How are poverty and health related? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 3 Poverty shapes the global burden of disease • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 4 The poor have less access to quality health services • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 5 What is the relationship between poverty and TB? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Why the poor are at greater risk of TB • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • How TB causes and perpetuates poverty: the socio-economic costs of TB to patients and families • • How TB causes and perpetuates poverty: TB hinders economic growth and social development • • • • The reinforcing cycle of poverty and TB • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Does effective TB control reduce poverty? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • DOTS effectively reduces the risk of TB • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • How DOTS contributes to poverty reduction• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Is DOTS sufficiently pro-poor? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • DOTS may not be reaching the poor • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Why may DOTS be failing to reach the poor? • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Poverty restricts health seeking along the pathway to cure • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Pathway to cure: barriers delay and impede access by the poor to DOTS • • • • • • • • • • • • • • • • • • • • • • • • • Factors that prevent or delay the poor from accessing DOTS • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • How should TB programmes improve access for the poor to DOTS? • • • • • • • • • • • • • • • • • • • • • • • • Improving access to meet the TB control targets • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Strategies by the TB programme to improve access by the poor to DOTS • • • • • • • • • • • • • • • • • • • • • • • • • Strategies beyond the TB programme • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Integrating poverty into TB control: next steps • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • List of Figures 6 7 8 9 10 11 12 13 13 13 15 16 16 17 22 23 23 25 25

Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13

Proportion of population living below US$ 1 a day in six countries in the Western Pacific Region • • • Health status and poverty, Viet Nam • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • The benefit incidence of public spending by income quintile, Cambodia 2002 • • • • • • • • • • • • • • • • • • • TB burden in poor and rich countries • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • TB prevalence rates among the poor and non-poor, Philippines • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Trends in smear-positive TB, Viet Nam: 1990 - 1999 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Prevalence of smear-positive TB by ethnic group, China • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Treatment success rates in the seven high burden countries, Western Pacific Region• • • • • • • • • • • • • • • • The model: Barriers along the pathway to cure • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • How barriers prevent the poor from accessing DOTS • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Reasons for treatment delay, China • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Where TB symptomatics go for help, Philippines • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Case detection rates in high burden countries in the Region, 2002 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • List of Boxes

2 4 5 7 7 9 10 12 16 17 18 21 23

Box 1 Box 2

Gender and TB: some evidence from Viet Nam • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 8 TB and social exclusion: ethnic minorities, prisoners, and people living with HIV/AIDS • • • • • • • • • • • • • 10

References • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 26 Endnotes • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 31

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

LIST OF ABBREVIATIONS

List of Abbreviations ADB AIDS ARI CHW DALYs DOTS DOT GDP GNI GFATM HDI HIV IEC IMR MDGs NGOs NTP PHC PRSP TAG TB TB/HIV UNDP WB WHO WPRO Asian Development Bank Acquired immunodeficiency syndrome Annual risk of infection Community health worker Disability-adjusted life years Directly observed treatment, short-course Directly observed treatment Gross domestic product Gross national income Global Fund to Fight AIDS, Tuberculosis and Malaria Human Development Index Human immunodeficiency virus Information, education and communication Infant mortality rate Millennium Development Goals Nongovernmental organizations National TB Programme Primary health care Poverty Reduction Strategy Paper Technical Advisory Group Tuberculosis HIV-associated TB United Nations Development Programme World Bank World Health Organization Western Pacific Regional Office

reaching the POOR

FOREWORD

Foreword In the Western Pacific Region, 1000 people die of tuberculosis (TB) every day; many of them are among the poorest and most vulnerable. TB is a disease of poverty that thrives on deprivation and inequality. Attacking those in the most economically and socially productive age group of 15–54, TB leaves disaster in its wake. The loss of productive labour and frequently unaffordable expense of seeking treatment can thrust TB patients and their families deeper into poverty. When aggregated to the national level, the cost of TB to economic development and poverty reduction is tremendous. In 1999, WHO's Regional Committee for the Western Pacific declared TB a "regional crisis". Launched in response, the Stop TB Special Project aims to reduce the prevalence and mortality of tuberculosis in the Region by half by 2010. While important progress has been made in the battle against TB, we must strive to reach those most in need–poor and marginalized communities in countries with the highest burden of TB in the Region–to ensure the 2010 target is met. The Western Pacific Region is seeking to integrate a pro-poor focus in TB control programmes. Reaching the poor: challenges for TB programmes in the Western Pacific Region is the first step in this direction. Targeting national TB programme managers and policy-makers from countries and areas in the Western Pacific Region, this publication aims to increase awareness of the relationship between poverty and TB. This will be followed by a Regional Framework on TB and poverty that will systematically integrate poverty into TB control. This initiative builds on a series of recent events reflecting the growing commitment internationally to addressing poverty and TB as a joint challenge. Both poverty reduction and TB control are integral to the Millennium Development Goals, which WHO is committed to supporting. In 2002, the Stop TB Partnership in Geneva, of which WHO Headquarters serves as Secretariat, created a TB-Poverty Advisory Committee and commissioned further work on TB and poverty. In September 2003, the Regional Committee for the Western Pacific called for a focus on poverty in TB control to improve access by the poor to DOTS. This resolution followed a recommendation made in an external thematic evaluation of the Stop TB Special Project of the Western Pacific Regional Office conducted in early 2003. Building on work done at the global level, Reaching the poor: challenges for TB programmes in the Western Pacific Region presents evidence from the Region on the relationship between poverty and TB. We hope to assist national TB programme managers and policy-makers improve access for the poor to DOTS. Notably, the Stop TB Unit and the Health Systems Unit in the Western Pacific Regional Office developed this publication jointly. We hope that such collaboration will be strengthened and expanded to other technical programmes in the days ahead. Now it is time to move beyond "business as usual", to promote greater equity in access to TB control services, thus ensuring that the poor and marginalized can particularly benefit from DOTS.

Shigeru Omi, MD, Ph.D Regional Director

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

EXECUTIVE SUMMARY

Executive Summary Globally, over 98% of the deaths caused by tuberculosis (TB) annually are in developing countries. Within the Western Pacific Region, the seven countries that account for 94% of the TB prevalence are low or lower middle-income economies. Within countries, as well, poor and marginalized communities suffer disproportionately from TB. Importantly, TB affects the most economically and socially productive age group, as 77% of TB deaths occur within the ages of 15 – 54. This evidence points to the important relationship between poverty and TB. The deprivation associated with poverty, such as overcrowding, poor ventilation and malnutrition, increases the rate of transmission and progression from infection to disease. In turn, the costs of TB can further impoverish poor households. This is because poor households must dedicate a larger proportion of their income to meet the direct and indirect costs of seeking TB care than the non-poor. The opportunity costs are likewise higher for the poor than non-poor. For the poor, a decrease in productivity or an increase in time away from work because of illness leads to a reduction in income. Moreover, coping mechanisms employed by poor households during periods of illness may reduce household productivity in the long-term. TB has important social costs as well, which are more likely to affect women with TB than men. For example, stigma and isolation resulting from TB can reduce an individual's social position. Since the economic and social costs of TB are high, effective TB control, such as directly observed treatment, short-course (DOTS), may indirectly reduce poverty, through longer lives and increased productivity. However, the extent to which national TB programmes (NTPs) respond to the needs of the poor cannot be accurately assessed because routine monitoring and recording systems do not provide information on patients by socioeconomic status. Health-related research from beyond TB offers many reasons to suspect that, even with free diagnosis and treatment, DOTS may not be reaching the poor. Evidence from within TB is beginning to reveal similar trends: the non-poor may be capturing most of the benefits of DOTS, and DOTS programmes may be failing to reach many of the poor. In particular, the current case detection strategy may be "missing" cases, especially in hard-to-reach or marginalized populations. DOTS may be failing to reach the poor because of the constraints poverty may place on health seeking. Specifically, poverty-related barriers that obstruct access along the pathway to cure (from recognition of symptoms to achieving a cure) may delay or prevent poor TB patients from accessing TB control services. These barriers include: physical barriers; lack of information and awareness; economic costs; and lack of health system responsiveness, in both the public and private sectors. Such impediments may undermine progress towards achieving the Regional targets for TB control. Strategies are thus needed to improve the accessibility of DOTS for the poor. These strategies will also begin to address inequity in the burden of TB and access to TB control. The first priority of NTPs is to ensure the availability of quality TB services by implementing DOTS across the country. As a next step, NTPs should focus on improving access for the poor to DOTS. A number of strategies can be identified to address the aforementioned barriers, which will be elaborated upon further in the forthcoming Regional Framework on TB and poverty.

reaching the POOR

1 What is poverty?

An important feature of poverty is that it often overlaps with and reinforces other types of social exclusion, such as those based on race, gender or ethnicity.

reaching the POOR

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

WHAT IS POVERTY?

What is poverty? Traditionally, poverty has been conceptualized in terms of income, with the poor being defined as those living below a given income level. Poverty can be also understood as pronounced deprivation in well-being.1 However, poverty is increasingly recognized as being a multidimensional phenomenon, encompassing not just low income but also lack of assets, access to skills, resources, opportunities, services, and power or voice to influence decisions that affect your life. This more comprehensive understanding of poverty also captures better how the poor themselves define their own situation.2 An important feature of poverty is that it often overlaps with and reinforces other types of social exclusion, such as those based on race, gender or ethnicity. In the Western Pacific Region, the social exclusion of indigenous people is often reflected in the relatively lower levels of development in the areas where they live. 3 The Human Development Index (HDI) of provinces in the Philippines, for example, ranges from a high of 0.925 in Metro Manila, to a low of 0.372 in provinces peopled by indigenous populations and other marginalized groups, including the Muslims of Mindanao.4 Using a measure of income poverty, the World Bank estimates that there are 1.2 billion people living in extreme poverty, equal to 23.3% of the population in low and middle-income countries.5 An estimated 24% of the world's poor live in the 6 East Asia and Pacific region. Figure 1 shows the percent of the population living on less than US$ 1 a day in six countries in the Western Pacific Region: five countries with a high burden of tuberculosis and Malaysia, one of the seven countries with an intermediate burden of tuberculosis. Figure 1: Proportion of population living below US$ 1 a day in six countries in the Western Pacific Region. 30 Source: Asian Development Bank 2000

Percentage of Population

in a

La Ma Vie Mo Ph oP ilip lay tN ng DR pin oli sia am a e

reaching the POOR

2 How are poverty and health related?

For poor households, the relationship between poverty and health is clear: poverty leads to ill health, and ill health leads to increased poverty.

reaching the POOR

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

HOW ARE POVERTY AND HEALTH RELATED?

How are poverty and health related? 2.1 Poverty shapes the global burden of disease Poverty and health are closely interrelated. A simplified representation of this interrelationship consists of two reinforcing cycles:

! !

The vicious circle: Poverty breeds ill health Ill health causes poverty The virtuous circle: Higher income is linked to good health Good health is linked to higher income and welfare

Whether at household, community or national level, poverty is recognized as a significant determinant of ill health. The global pattern of disease mirrors inequalities in income and wealth distribution across countries. The disparity in the global burden of communicable diseases7 is stark: the 20% of the global population living in the poorest countries suffers almost half the death and disability caused by communicable diseases, while the 20% of the global population living in the richest countries experiences a mere 4.2% of global 8 mortality and 2.6% of disability-adjusted life years (DALY) loss. Further, within countries, communicable diseases affect the poor more than the rich. Figure 2 illustrates the distribution of malnutrition and infant mortality among urban, rural and rural poor populations in Viet Nam. Recent evidence shows that the poor are also beginning to bear a "double burden" of disease, since they often suffer disproportionately from non-communicable or life-style diseases and common mental disorders.9,10 These inequalities between the health of the poor and non-poor are inequitable. In 11 other words, they are avoidable, unfair and unjust. Most importantly, global health inequalities are widening. Figure 2: Health status and poverty, Viet Nam.

For poor households, the relationship between poverty and health is clear: poverty leads to ill health, and ill health leads to 40 increased poverty. In other words, ill health is both a cause of greater poverty and an impediment to escaping poverty. Research 28.4 26.7 has shown that good health is central to the 21.8 survival of poor individuals and households, as it translates into higher productivity and 9.6 10.4 income, while ill health means less income, frequently unaffordable expenditures and Malnutrition IMR greater poverty. Evidence is also mounting on the relationship between higher levels of URBAN RURAL RURAL POOR economic growth and lower burdens of ill health at the level of countries or societies. The Commission on Macroeconomics and Health, for example, calls attention to the powerful linkages between health and poverty reduction and long-term economic growth.12 Source: Bhushan 2001

reaching the POOR

HOW ARE POVERTY AND HEALTH RELATED?

2.2 The poor have less access to quality health services Evidence shows that, despite their greater risk of becoming ill and their relatively poorer health status, the poor have systematically lower access to health services than the non-poor (see Figure 3). In fact, it has frequently been observed that the availability of good medical care tends to vary inversely with the need for it in the population served. This phenomenon is 13,14 Figure 3: The benefit incidence of public spending known as the inverse care law. by income quintile, Cambodia 2002. 30 % 25 %

Governments, especially those in developing countries, may lack the resources to invest adequately in social services, from health and education to agriculture, which contribute to poverty reduction. Inadequate investments compromise the availability and quality of health services. Further, evidence shows that the allocation of limited resources tends to benefit the non-poor at the expense of the 15 poor.

Source: Ensor 2002, in Kingdom of Cambodia 2003

% of public spending

20 % 15 % 10 % 5% 0%

Lower

L-middle

Middle

U-middle

Upper HEALTH CENTERS

NATIONAL HOSPITALS

DISTRICT/PROVINCE HOSPITAL

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

3 What is the relationship between poverty and TB?

Within countries, the distribution of TB is higher among the poor than among the non-poor

reaching the POOR

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

WHAT IS THE RELATIONSHIP BETWEEN POVERTY AND TB?

What is the relationship between poverty and TB? Tuberculosis (TB) is the second largest infectious cause of death among adults, after HIV/AIDS. Of the 1.8 million deaths caused by TB annually, 98% occur in 16 developing countries. Figure 4 shows the burden of TB deaths and DALYs lost among the 20% of the global population living in the poorest Figure 4: TB burden in poor and rich countries. countries compared with the 20% of the population living in Source: Gwatkin, Guillot 2000 70 the richest countries. 60

There are an estimated two million cases of all types of TB in the Western Pacific Region. Seven high burden countries – Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam – together account for 94% of TB prevalence in the Region. Five of these seven countries are low-income economies, with a 17 GNI per capita of US$ 735 or less. The remaining two, China and the Philippines, are lower middle-income economies. 18

50 40 30 20 10 0

% of all deaths due to TB % of DALYs lost to TB POOREST 20% RICHEST 20%

Within countries, as well, the distribution of TB is higher among the poor than the non-poor. In the Philippines, for example, the prevalence rate of smear-positive TB was found to be 1.6 times higher in urban poor communities than in non-poor 19 urban communities (see Figure 5). In China, 78% of TB patients and their families were found to have per capita annual family income lower than the average for the locality.20 The TB mortality rate in poor rural China was found to be nearly three 21 times higher than that in more developed urban areas. A study in northern Viet Nam observed that three times as many TB patients belonged to the lowest income quintile compared to those in the general study population. 22 3.1 Why the poor are at greater risk of TB While TB is not exclusively a disease of the poor, the deprivation associated with poverty increases the risk of TB infection and progression to disease. Poor living and working conditions, characterized by over-crowding and inadequate ventilation, can create an environment that breeds disease, especially TB.23 In the Philippines, the annual risk of infection (ARI) was found to be 2.5 times higher among the urban poor than among the urban non24 poor. Food insecurity and poor nutrition increase the likelihood that infection will progress to disease.25,26,27 Figure 5: TB prevalence rates among the poor and non-poor, Philippines. 6 Source: Tupasi et al. 2000

Sm + TB rate per 1000

5 4 3 2 1 0

National

Urban non-poor

Urban poor

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

WHAT IS THE RELATIONSHIP BETWEEN POVERTY AND TB?

3.2 How TB causes and perpetuates poverty: the socio-economic costs of TB to patients and families The cost of TB to poor households can be devastating. The costs of seeking TB treatment consist of direct costs (such as the cost of diagnosis and treatment), indirect costs (such as the cost of food and transport) and opportunity costs (such as wages lost). In China, the total cost of seeking treatment was found to be equivalent 47 to 89% of average family income per capita. Poor households dedicate a larger proportion of their income to seeking care for TB than non-poor households do. A study in Malawi found that the total cost for TB diagnosis is lower for the poor than that for the non-poor. However, as a percentage of monthly income, the cost is three times higher for the poor than that for Box 1 Gender and TB: some evidence from Viet Nam the non-poor, accounting for 584% and 174% of monthly income after food Globally, TB is the leading infectious cause of death among women, killing expenditure, respectively.48 28 In Thailand, the out-of-pocket expenditure of seeking care is more than 15% of annual income for households living below the poverty line.49 More worrisome is the burden of opportunity costs on poor households, which may be two to three 50 times the direct cost of seeking treatment. These costs are higher for the poor than for the non-poor because the poor often work in the informal sector or earn income from their physical labour. In such circumstances, a decrease in productivity or an increase in time away from work because of illness leads to a reduction in 51 income. Loss of productivity may also result because TB can push a person with poor nutritional status into a state of malnutrition.52 Estimates suggest that, on average, a TB patient loses three to four months of work time annually, equivalent 53 to 20% of annual household income. This estimate excludes the economic and social costs to the household and other family members. In many countries, the traditional social safety nets that support families during

more women every year than all causes of maternal mortality combined. On average, 3.5 million women develop active TB annually.29

In the Western Pacific Region, twice as many new male smear-positive TB cases than female cases are reported annually30 However, research on TB and gender is in its early stages. The reasons for the reported male-female gap are thus still unclear. Some studies suggest that the figures reflect a true difference in incidence of disease.31 In turn, other studies show that the gap is at least partly due to gender-related barriers, resulting in a smaller share of women than men being reached by TB programmes.32 Regardless of whether more men or women are infected with TB, evidence suggests that women between 10-40 years of age have up to a 130% higher risk of progressing from TB infection to disease than men.33 Globally, case 34 fatality rates are higher among women. It is also clear that the poverty-related determinants of TB infection and health seeking weigh more heavily on women than on men. Everywhere, women work longer hours, control fewer productive assets, earn less than men and face unique reproductive health risks.35 Women's health seeking is thus constrained by their lower socio-economic status and reduced access to information and economic resources. In this manner, poor women may be doubly disadvantaged. Evidence points to the specific constraints women may face when seeking to access TB services globally.36 These issues are clearly described by a number of studies from Viet Nam that seek to explain the male-female gap in notification of new smear-positive TB. Mirroring global trends, evidence from these studies suggests that women seek care from less qualified health providers, fewer women present for diagnosis, and women experience longer delay before receiving treatment than men. This suggests that the male-female gap may arise from gender-related barriers to diagnosis and treatment. Continued

reaching the POOR

WHAT IS THE RELATIONSHIP BETWEEN POVERTY AND TB?

periods of crisis have been eroded. Neither the state nor other actors have filled this gap, leaving families to fend for themselves.54 The poor are more vulnerable to serious or prolonged illness; meagre resources are dedicated to daily basic needs, leaving little, if any, savings to buffer against unexpected shocks or periods of 55 income loss. The coping mechanisms used by poor families in such circumstances may reduce household productivity in the longer term. Families may reduce expenditure on items such as food and clothing to meet the direct and indirect costs of treatment.56 The loss of productive labour to illness may be offset by other family members, 57,58 including children, who may be pulled out of school. Households may also sell their assets or borrow money to cover the cost of seeking treatment. For example, a Gender and TB continued study in Cambodia observed that 40% of The male-female ratio of new smear-positive TB cases in Viet Nam reflects the Regional pattern, having increased from 1.6:1 in 1990 to 2.1:1 in new landlessness was due to ill health.59 1999 (see Figure 6).37 However, studies show that the prevalence of longSelling assets, especially land, can deprive term cough among men and women is not significantly different.38 households of a future income stream, while taking children from school forfeits Figure 6: Trends of smear-positive TB, Viet Nam: 1990-1999. Source: Viet Nam National TB Programme Review 2003 40000 the long-term economic advantages of 35000 schooling. 30000

People

TB has important social costs as well. Stigma and isolation resulting from TB, for example, can reduce an individual's power and social position. Numerous studies show that stigma is more likely to affect women with TB than men. Negative social responses to women's illness include stigma and isolation from families and the wider community. In contrast, men are more likely to worry about the financial and economic consequences of their illness, such as loss of income, reduced productivity and possible job loss.60,61,62 3.3 How TB causes and perpetuates poverty: TB hinders economic growth and social development When the costs borne by individual TB patients and their families are aggregated, the loss to national productivity and socioeconomic development can be

25000 20000 15000 10000 5000 FEMALE

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In Viet Nam, evidence suggests that men and women recognise their symptoms and seek health care at roughly the same time. However, women are more likely to self-medicate and consult less qualified health providers, while men seek care directly from hospitals.39 The mean expenditure per health action for men TB patients was found to be almost twice that of women TB patients.40 Women thus take longer to contact a qualified medical provider, where a smaller share of women are likely to present for diagnosis than men. Those women who do present for diagnosis experience longer delay and are less likely to be diagnosed than men.41,42 This may be because women are less likely to present with typical TB symptoms, such as cough, sputum expectoration and haemoptysis than men. In turn, absence of cough and sputum expectoration was significantly associated with provider delay.43 A significantly higher proportion of men (36%) than of women (14%) reported giving sputum samples at hospitals.44 Female TB patients, who are requested to give sputum samples, are less likely than male TB patients to return for the requested follow-up.45 Conversely, studies revealed that women are perceived to be more compliant than men.46

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

1999

WHAT IS THE RELATIONSHIP BETWEEN POVERTY AND TB?

tremendous. In the Western Pacific Region, 77% of TB deaths occur within the ages of 15-54, the most economically and socially productive age group. The global cost of TB is estimated to amount to US$ 12 billion annually. In 1998, for low and 69 middle-income countries, this meant an annual loss of approximately 0.2% of GDP . 3.4 The reinforcing cycle of poverty and TB The interrelationship between poverty and TB is further compounded by obstacles that delay or deter health seeking by the poor. The high cost of seeking treatment, coupled with low income and other physical and social barriers, such as distance to a health facility and stigma, reduce the ability of the poor to access health services. Difficulties in access may be further exacerbated by inadequate quality and coverage of health care services in both the public and private sectors. Thus, the poor are less likely to seek and receive timely diagnosis and treatment for TB. A study in Manila found that respondents with low family income (less than P2000 a 70 month ) were seven times more likely than those with medium and high incomes 71 not to seek medical care. These issues are discussed in greater depth in section 5. Box 2 TB and social exclusion: ethnic minorities, prisoners, and people living with HIV/AIDS Ensuring that quality TB control services are available to the numerous ethnic groups in the Western Pacific Region poses a particular challenge to the TB programme. Evidence from the Region suggests that national TB programmes (NTPs) are not reaching these groups successfully. For example, the 1990 National Prevalence Survey in China found the prevalence rate among the Uygur and Li to be almost twice the national average (see Figure 7).63 In Viet Nam, reaching ethnic minorities in the mountainous provinces, especially in the north-western part of the country, was recently identified as one of the main challenges for the NTP . 64 Figure 7: Prevalence of smear-positive TB by ethnic group, China. 300 250 200 150 100 50 0 Source: Ministry of Health of the People's Republic of China 2000

Mi ao

Me n

Other socially marginalized groups, such as the homeless and prisoners, are at significantly higher risk of contracting TB than is the general population. For example, the prevalence rate of TB in prisons may be up to 100 times higher than that in the general population.65 Globally, 90%-95% of prisoners are men between 15-44 years of age from socially disadvantaged populations.66 Crowded conditions and poor ventilation make prisons hotspots for the transmission of TB. Confined for long periods, prisoners may also lack recourse to medical care.67 People infected with HIV/AIDS have a 50% chance of developing active TB, although the lifetime risk for HIV-negative people is only 5%-10%, making TB the leading killer of people infected with HIV/AIDS.69 In many countries, HIV/AIDS is a highly stigmatized disease, which may deter health seeking as HIV/TB co-infection becomes more common.

Ha H sak ui e

Tuj ia

gu r

reaching the POOR

4 Does effective TB control reduce poverty?

Almost twice as many patients successfully complete their treatment under DOTS than do those in non-DOTS programmes. In 2001, the regional treatment success rate for new smear-positive TB cases stood at 92%.

reaching the POOR

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

DOES EFFECTIVE TB CONTROL REDUCE POVERTY?

Does effective TB control reduce poverty? 4.1 DOTS effectively reduces the risk of TB Economic growth, to the extent it reduces poverty, has a role to play in TB control. Reducing poverty mitigates some of the environmental factors that nurture the spread of TB, such as poor housing and malnutrition, and thereby reduces the risk of TB infection. But reducing poverty does not diminish the existing pool of infectious TB cases, which are the primary source of infection. Without treatment, seven in ten people with infectious TB will die of the disease, on average within four to five years of onset.72 Thus, the most effective means of tackling the high burden of TB is through a comprehensive national TB control programme that cuts the cycle of transmission, infection and disease. TB control ensures that active TB cases are cured, reducing the risk of TB infection. The Stop TB Special Project in the Western Pacific Region aims to reduce the prevalence and mortality due to TB by half by 2010. The project intensifies efforts, especially among countries with a high burden of TB, towards realizing the three key global targets of 100% DOTS coverage, 70% case detection rate and 85% treatment success. DOTS is the basic strategy employed to realize this goal. The five elements of DOTS – government commitment and resources; case detection by sputum microscopy; standardized treatment with directly observed treatment (DOT) for at least the first two months; regular uninterrupted supply of anti-TB drugs; and standardized recording and reporting – together constitute the minimum package of 73 interventions necessary for effective tuberculosis control. Evidence shows that DOTS is an effective strategy for TB control. Almost twice as many patients successfully complete their treatment under DOTS than do those in 74 non-DOTS programmes. In 2001, the regional treatment success rate for new smear-positive TB cases stood at 92%. Figure 8 presents the treatment success rate in the seven countries with a high burden of TB. The high rate of treatment success means decreasing prevalence and mortality. Figure 8: Treatment success rates in the seven high burden countries, Western Pacific Region. 100 90 80 70 60 50 40 30 20 10 0 Source: WHO 2003a

Cambodia

China

Lao PDR

Mongolia

Papua Philippines New Guinea

Viet Nam

Evidence from China illustrates the effectiveness of the DOTS strategy in TB control. Five provinces in western China participated in the World Bank-funded TB control project starting in 1992. The project accelerated DOTS coverage in these

reaching the POOR

DOES EFFECTIVE TB CONTROL REDUCE POVERTY?

areas. Over a decade, these provinces experienced a 27.2% decrease in the prevalence of smear-positive pulmonary TB. In comparison, the seven provinces in western China not covered by the project saw a 7.3% increase in the prevalence of 75 smear-positive pulmonary TB. 4.2 How DOTS contributes to poverty reduction Since the social and economic costs of TB can be very high, reducing TB may also reduce poverty indirectly, through longer lives and increased productivity of TB patients and their families. Moreover, since it provides free diagnosis and treatment, DOTS is specifically designed to reduce the economic burden of TB. A review of the literature finds that DOTS is the most cost-effective TB intervention for both the 76,77 provider and the household in low and middle-income countries. DOTS can also address some of the opportunity costs of seeking TB treatment by ensuring effective cure and early return to work. In a study in Jakarta, among patients who were unemployed when treatment was initiated, half were jobless because of TB symptoms. After two months of weekly DOT, 40% of those unemployed because of TB were employed and another 20% started working after 78 four months. The successful cure rates and lower cost of treatment under DOTS can also partly address the social costs of TB, such as stigma. 4.3 Is DOTS sufficiently pro-poor? The effectiveness of DOTS is clearly reflected in the high degree of political commitment for TB control globally and, more specifically, the high treatment success rates in countries implementing DOTS. However, the assumption that, by design, DOTS is reaching the poor has recently been thrown into debate. Presently, the extent to which NTPs respond to the needs of the poor cannot be accurately assessed because routine monitoring and recording systems do not provide information on patients by socio-economic status. Yet, an increasing body of evidence suggests that even though DOTS extends free diagnosis and treatment, the nonpoor may be capturing most of the benefits and DOTS programmes may, in fact, be "missing" many of the poor. 4.4 DOTS may not be reaching the poor While the TB community is just beginning to address this question, health-related research from beyond TB offers many reasons to suspect that, even with free diagnosis and treatment, DOTS may not be reaching the poor. This phenomenon has been called the fallacy of equitable impact: namely, the assumption that

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

DOES EFFECTIVE TB CONTROL REDUCE POVERTY?

interventions against conditions that are concentrated primarily among the poor can be expected to benefit primarily the poor victims of those conditions.79 On TB specifically, two studies from Malawi suggest that the poor may not be benefiting from DOTS. In Lilongwe, TB notification rates from a densely populated planned area, characterized by better socioeconomic status, were compared with those of a similarly populated unplanned squatter area. The study concluded that 46% of expected smear positive 80 TB cases were "missing" from the squatter area. A cross-sectional survey of TB patients showed that 62% were poor. Although this was a higher proportion of poor than that seen in the general population, the poor came from planned areas, indicating that the very poor from unplanned areas were not accessing DOTS.81 Similarly, in northern Brazil, TB notification rates were higher 82 among middle socio-economic areas and lower in the more deprived areas. These studies throw into question the assumption that DOTS is reaching the poor and suggest rather that the current detection strategy may, in fact, be "missing" cases, especially in hard-to-reach or marginalized populations.

reaching the POOR

5 Why may DOTS be failing to reach the poor?

reaching the POOR

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

WHY MAY DOTS BE FAILING TO REACH THE POOR?

Why may DOTS be failing to reach the poor? 5.1 Poverty restricts health seeking along the pathway to cure The vicious cycle of TB and poverty is reinforced by constraints poverty may place on the health seeking of the poor. Poverty can influence the way the poor perceive their illness, their health seeking behaviour, when and where they access diagnosis and proper treatment, the quality of care they receive and whether they achieve a successful outcome. Such barriers delay health seeking and lengthen the overall process of achieving a cure, resulting in greater expense and lost income, and increased poverty. The stages of health seeking by TB patients, from recognition of symptoms to cure, may be represented as a linear process or pathway to cure. Figure 9 presents a model that describes the hypothesized attrition rates for poor and non-poor TB cases, through the stages along the pathway to cure. The space between stages represents determinants of progress to the next stage, including barriers that may impede progress. In Figure 9, the size of the bars decrease at each successive stage along the pathway to cure, reflecting lost TB suspects(the model assumes that all TB cases recognize their symptoms). Figure 9: The model: Barriers along the pathway to cure. Similarly, moving along the Source: Adapted from Uplekar et al. 1999 pathway, the ratio of non-poor to NON-POOR TB CASES poor TB patients increases. POOR TB CASES BARRIERS

Symptoms

Health Services

TB Diagnosis

Treatment

Cure

In the Western Pacific Region, the primary challenge is accelerating case detection. The attrition rate from treatment to positive outcome is relatively low. Thus, focusing on the stages representing case detection, those prior to diagnosis, may be more useful for refining the TB control strategy in the Region.

5.2 Pathway to cure: barriers delay and impede access by the poor to DOTS Little evidence is available on what specifically may prevent poor and marginalized TB symptomatics from seeking care at each stage of the framework outlined above.

reaching the POOR

WHY MAY DOTS BE FAILING TO REACH THE POOR?

However, research on factors that delay health seeking provides useful insights. Factors that may merely cause delay in the case of non-poor TB suspects may prove insurmountable to the poor, thus effectively denying them access to TB services. Higher costs may force poor patients away from the pathway to cure at earlier stages. For example, delay tends to increase the overall economic burden of TB 83,84 treatment for the poor. Figure 10 illustrates how these barriers may delay and prevent the poor from accessing TB services by forcing them away from the pathway to cure. Figure 10: How barriers prevent the poor from accessing DOTS.

Public Sector

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Delays in seeking treatment have been explored in numerous studies; however, few offer a socio-economic analysis of delay.85 The few studies that explore delay among different social groups note a variance in patient and provider 86 delay. For example, both patient and provider delay are longer for women than for men. As well, low income has been identified as an important source of delay and default.87 5.3 Factors that prevent or delay the poor from accessing DOTS

A number of studies have identified various factors that contribute to delay, and 88,89,90,91 thus, may prevent poor TB suspects from accessing DOTS. Figure 11 presents the factors causing treatment delay identified by a study in China. Such factors may be strongly associated with or compounded by poverty. Each of these factors may act as a barrier to TB services for the poor at multiple stages along the

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

WHY MAY DOTS BE FAILING TO REACH THE POOR?

Figure 11: Reasons for treatment delay, China.

Financial

45% 10% Not informed

pathway to cure. For example, in Figure 10, a single factor may create a barrier at one or more stages along the pathway to cure. These factors are described below.

a. Physical barriers: In many settings across the Region, living a long 10% 12% Inaccessible distance from health facilities is the most frequent Others health providers 23% barrier to access faced by the poor. Other physical Ill perception barriers, from difficult terrain to living in remote Source: Ministry of Public Health of the People's Republic of China 1990 island communities, can impede physical access to health services. Distance to health facilities is an important physical barrier. Relative to urban residence, rural residence is also known to contribute significantly to delay.92,93 A study in China observed that farmers experience 94 longer delay in seeking treatment. This may be especially true for people from ethnic minorities, who typically live in remote or mountainous areas. Health facilities in rural areas may be more difficult to access, have more poorly trained staff, and lack proper supervision of health staff.95 b. Lack of knowledge and awareness: Poverty can limit educational opportunities and access to information, in general. Lower education is significantly associated with delay.96,97,98,99 Low education has 100 also been linked to poor knowledge and erroneous beliefs about TB. For example, in a study in Manila, the urban poor thought that vices (e.g. drinking, gambling) and hard work played a larger role in contracting TB than did person-toperson transmission.101 In a Mongolian study, patients who were afraid of being diagnosed with TB delayed seeking treatment.102 Lack of information on TB may also reduce the probability that a person will accept a diagnosis of TB because of apprehensions about the disease, diagnosis by sputum microscopy (since X-ray may typically be seen as the proper diagnosis tool) and possible cure. Low education and knowledge of TB may also affect the way symptoms and possible treatment are perceived and understood by individuals and communities, which strongly influences health-seeking behaviour. Personal health may not be regarded as a priority when survival itself is a struggle.103, 104 Studies have found that, in some settings, women may suffer silently for longer periods of time because of cultural expectations, forcing them to accord lower priority to their own health.105 TB is a disease strongly associated with traditional beliefs and stigma. In the 106 Philippines, TB is referred to as shameful and as a bad mark on the family. In Viet Nam, TB has been described as a dirty disease that mainly affects poor people and is caused by hard work, overwork and bad hygiene.107

reaching the POOR

WHY MAY DOTS BE FAILING TO REACH THE POOR?

Studies reveal that stigma is an important factor contributing to delay, as it seems to weigh strongly on patients' decisions regarding diagnosis and treatment. TB symptomatics who felt that they would be ostracized because of TB delayed seeking treatment longer.108 Women, especially, may "shop around" for a more appropriate 109 diagnosis and treatment. Some studies have found that women may wait up to twice as long as men before seeking treatment, citing fear of social isolation from families and community.110,111 Upon diagnosis, TB patients may not accept the diagnosis, or may become 112,113,114 frustrated, disappointed or worried. This negative response to TB diagnosis may result in their unwillingness to be officially registered as TB cases in health facilities.115 Patients may opt out of treatment or seek treatment from a private provider because daily visits to the health centre can identify them as TB patients. This is especially true for women who are more susceptible to stigma and wish to 116,117,118 keep their condition a secret. Importantly, a study in Viet Nam suggests that, once diagnosed, patients are likely to revert to a traditional understanding of TB.119 Such negative responses to TB may also influence treatment outcomes. Notably, social support, such as that offered by families, has been positively associated with health seeking and treatment adherence by studies in the Philippines and 120,121 Singapore. c. Economic barriers: Although DOTS provides free diagnosis and treatment, repeated visits to health facilities are required. The cost of transportation and food, coupled with lost income because of time away from work, may be more than poor TB patients 122 or families can afford. A study from Malawi estimated that on average, TB patients spent US$ 13 and lost 22 days from work at the diagnosis stage alone.123 In a study in Viet Nam, TB patients explained that poverty forced them to choose to work instead of 124 undergoing treatment. Poverty forced patients to default from treatment in studies from India, Haiti and South Africa, while in other studies, TB patients cite economic constraints as a major factor leading to default.125,126,127,128,129,130 As well, patients may face additional costs not covered by DOTS. For example, the recent National TB Programme Review in Viet Nam found that although anti-TB drugs are provided free of charge, patients were required to purchase the syringes and 131 distilled water for the injection during the intensive phase of treatment. The opportunity cost of adhering to treatment appears to be different for men and women. Men are more likely to default because of pressure to return to work, alcohol and drug addiction. Pressure to do housework and the strain of keeping 132 their condition a secret seems to cause women to default. In other words, women are pressured by both the economic and social costs of TB while men are more

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

WHY MAY DOTS BE FAILING TO REACH THE POOR?

concerned with the economic burden. Interestingly, it has been reported that 133 women have higher treatment compliance rates than men. d. Lack of health system responsiveness: Even when health services are available, the health system may not effectively respond to the needs of poor TB patients. Systems-related barriers that patients from poorer households may face include the (actual or perceived) poor quality of services, biased or undignified treatment from providers, and higher user fees. Public sector: In Cambodia, China and Viet Nam, the introduction of user fees in the public health system has created an environment where formal and informal public health fees taken together are similar to the amount charged by the private sector. This has increased inequality between income groups and can deter or 134 delay the use of services. In addition, fees may not be seen to accurately reflect the perceived value of services. Services provided by public health systems are often described as involving long travel time, long waits, inconvenient hours, poor quality of care and inadequate staff with unfriendly attitudes. Poor perception of 135,136,137 health services is strongly associated with delay, particularly for women. The low regard for TB control services in public health centres is often based on the poor reputation of the public health system, in general.138 The quality of anti-TB drugs in public health facilities is also often perceived to be poor and patients anticipate a shortage of drugs and supplies. In India, the health centres' inconvenient hours forced a rush of patients just after opening time (9:00 a.m.). The rush prevented providers from offering the one-on-one support that could 139 encourage treatment adherence. General dissatisfaction with the quality of care discouraged TB patients in the Philippines from continuing treatment.140 Interestingly, one study found that in the Philippines, distrust in successful TB 141 treatment outcomes was higher in people with low incomes. In particular, TB programmes may fail to respond to the needs of specific groups because of provider bias. Within the public health system, formal or informal eligibility criteria may prevent patients from accessing TB services. A study in Viet Nam found that TB patients must have a fixed address to be eligible for treatment, 142 while those who are not eligible for treatment are referred to private practitioners. This practice can constitute a real barrier for homeless TB patients. A study from New Delhi documents the informal selection criteria developed by DOTS providers targeting patients who were seen to be at risk of treatment default. The criteria denied treatment to socially marginalized and vulnerable patients.144 Studies from Viet Nam found that it took doctors significantly longer to diagnose 144,145 women with TB than men. This delay may partially be exampled by provider bias in requesting sputum samples from women. The study in Viet Nam observed

The low regard for TB control services in public health centres is often based on the poor reputation of the public health system, in general.

reaching the POOR

WHY MAY DOTS BE FAILING TO REACH THE POOR?

that only 14% of female TB symptomatics reported giving a sputum sample in hospital compared with 36% of male TB symptomatics.146 Private sector: The accessibility of the private sector is reflected in the large number of poor and non-poor TB symptomatics in urban and rural areas who consult private health care providers. However, the quality of TB Figure 12: Where TB symptomatics go for help, Philippines. treatment offered by private practitioners is usually inadequate. TB patients are thus forced to make repeated visits to multiple Self Medication providers in search of quality TB treatment. None 43% 32%

The private sector is found to attract patients from all socio147 economic strata by paying attention to individual priories. In the Philippines, the private sector captures a large percentage of TB symptomatics who seek care, as seen in Figure 12.148 In a study in Viet Nam, 82% of patients from across socio-economic strata receiving treatment in a government TB centre had been in 149 contact with a private physician.

11.8% Traditional 1.7% 4.4% Healer Hospital

7.5% Public Clinic

Private Practice

Studies suggest that the level of care offered by private Source: Tupasi et al. 2000 practitioners is similar, or often inferior, to that available in public health facilities. Nevertheless, patients prefer the perceived confidentiality offered by private practitioners and therefore accept the poorer quality of care.150 Women, especially those from 15-24 years of age, are more likely than men to seek diagnosis and treatment from private practitioners. Convenient timing and location, cordiality, desire to keep TB diagnosis a secret, and fear of social stigma and rejection are among the reasons women cite for consulting private providers.151,152 As well, private fees may be only slightly higher than fees charged by the public health system, often with the added attraction of flexible payment 153 schemes and, possibly payment in kind. However, inadequate detection, diagnosis and treatment of patients by private physicians result in longer delay and higher costs for the poor. Patients presenting for diagnosis in a study in Ho Chi Minh City contacted 1.3 different health providers with an average of 2.5 visits per health care provider.154 Moving from one provider to the next delays treatment and involves considerable cost to the patient.

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

6 How should TB programmes improve access for the poor to DOTS?

There are three main reasons for TB programmes to focus on increasing access by the poor to DOTS: efficiency, equity and human rights.

reaching the POOR

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

HOW SHOULD TB PROGRAMMES IMPROVE ACCESS FOR THE POOR TO DOTS?

How should TB programmes improve access for the poor to DOTS? 6.1. Improving access to meet the TB control targets In the Western Pacific Region, the percentage of the population with access to DOTS has increased from 58% in 1998 to 77% in 2002, and 100% coverage by the end of 2005 is in sight. One major challenge remains: at 44%, the current case detection rate for new smear-positive TB cases is still far from the 70% target, as seen in Figure 13. The analysis in previous sections countries in the Region, 2002. shows that, even in countries where 100 DOTS has reached 100% coverage, 80 various obstacles may place TB 76 60 services beyond the reach of the 48 poor. There are three main reasons 40 48 34 for TB programmes to focus on 20 16 increasing access by the poor to 0 Ca Mo Ch La PN oP mb i na G ng DOTS. First, coupled with the DR oli od a ia disproportionate burden of TB among the poor, barriers to access have the potential to undermine progress towards achieving the regional targets. Strategies are thus needed to increase access to DOTS by the poor. Second, such strategies are also necessary to resolve inequities in the burden of TB and access to TB control. Third, this will also ensure that the basic human right to health is enjoyed by all. Figure 13: Case detection rates in high burden Source: WHO 2002

90 63 44

Ph il

Vie WP tN R ipp am i ne s

There are a number of strategies that can help improve access to DOTS by the poor. Some of these strategies can be initiated and/or implemented by NTPs; others require coordination with the larger development community. 6.2 Strategies by the TB programme to improve access by the poor to DOTS DOTS is a highly effective strategy for TB control. Thus, the first priority for NTPs is to ensure the availability of quality TB services by implementing DOTS across the country. As a next step, TB programmes should focus on improving access for the poor. This section presents information on innovative strategies TB practitioners are using to overcome barriers to access faced by the poor. As a result, evidence is slowly

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

HOW SHOULD TB PROGRAMMES IMPROVE ACCESS FOR THE POOR TO DOTS?

The first priority for becoming available on how to increase access by poor and marginalized groups to NTPs is to ensure DOTS. These interventions are still in their early stages and have not yet been rigorously evaluated or standardized. However, they suggest some ways forward. the availability of Each strategy must be refined based on further analysis and country-specific quality TB services situations. Nor is this an exhaustive list of strategies, as the evidence base for proby implementing poor strategies needs to be augmented through more systematic operational DOTS across the research. country. As a next a. Strategies to address physical barriers: step, TB programmes ! Target investments to improve or to expand TB services to poor or more remote geographic areas should focus on ! Community-based DOTS, which involves building partnerships with community improving access for members and groups the poor to DOTS. ! Innovative outreach strategies in remote and marginalized communities b. Strategies to address lack of knowledge and awareness: ! Appropriate information, education and communication (IEC) strategies and material specifically targeting poor, marginalized and vulnerable populations can effectively increase awareness, reduce misconceptions or stigma, and motivate health seeking c. Strategies to address economic barriers: ! NTPs can consider interventions that target low-income or marginalized populations by tailoring TB services to overcome economic barriers ! NTPs may mobilize financial support for TB patients by building alliances with communities, nongovernmental organizations (NGOs) and other government departments d. Strategies to address the lack of health system responsiveness: ! TB services: Maintaining the quality and responsiveness of DOTS is an important means of ensuring that all patients receive appropriate care ! Private sector: Public-Private Mix DOTS (PPMD) can effectively ensure that the poor have access to DOTS, by extending the coverage of DOTS to patients who seek care in the private sector ! Active case finding: The high prevalence of TB among certain high-risk populations, such as prisoners or those infected with HIV/AIDS, which are often marginalized and underserved, may indicate the need for active case finding ! Disaggregated data analysis and operational research: As this paper has shown, very little evidence currently exists on the extent to which NTPs are able to respond to the needs of poorer populations. Data should thus be collected and analysed by indicators of social exclusion, such as sex, income, ethnicity, locality and employment status. Such analysis enables the appropriate refinement of TB control strategies. More systematic operational research is also needed to

reaching the POOR

HOW SHOULD TB PROGRAMMES IMPROVE ACCESS FOR THE POOR TO DOTS?

identify social, linguistic and other non-financial barriers to access, and to propose and evaluate strategies to increase the accessibility of DOTS for the poor. 6.3 Strategies beyond the TB programme Efforts by the TB programme to address barriers that may prevent the poor from accessing TB control services can be further enhanced by a cross-sectoral response to the non-health determinants of poverty and TB. For example, by increasing access to education, improving water and sanitation and enhanced social protection through insurance schemes targeting the poor, important progress can be made in reducing poverty. Furthermore, efforts to make general health services more responsive to the needs of the poor will strengthen the quality and responsiveness of DOTS. 6.4 Integrating poverty into TB control: next steps Recognizing that poor, vulnerable and marginalized populations may have limited or no access to DOTS, the Stop TB Special Project is developing a Regional TB and poverty framework. The framework will provide tools to identify the barriers that prevent the poor from accessing TB services. Strategies to increase the accessibility of DOTS for the poor will be outlined further. The framework will thus promote a more systematic response from NTPs. By integrating a pro-poor focus in TB control, the framework will contribute to reaching the TB control targets by 2005.

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

REFERENCES

References Asian Development Bank. Key Indicators 2003: Education for Global Participation. Manila, Asian Development Bank, 2003. Ahlburg D. STOP TB Initiative 2000 Report: The Economic Impacts of Tuberculosis. Ministerial Conference. Amsterdam, World Health Organization, 2000. Auer C. et al. Health seeking and perceived causes of tuberculosis among patients in Manila, Philippines. Tropical Medicine and International Health, 2000, 5(9):648-656. Barnhoorn F., Adriaanse H. In search of factors responsible for non-compliance among tuberculosis patients in Wardha District, India. Social Science and Medicine, 1992, 34(3): 291-306. Balasubramanian V., Oommen K., Samuel R. DOT or not? Direct observation of antituberculosis treatment and patient outcomes, Kerala State, India. International Journal of Tuberculosis and Lung Disease, 2000, 4(5):405-413. Bhushan I. Presentation to Health Systems Development TAG. Manila, World Health Organization, Regional Office for the Western Pacific, 2001 (powerpoint presentation). Borgdorff M et al. Gender and tuberculosis: a comparison of prevalence surveys with notification data to explore sex differences in case detection. International Journal of Tuberculosis and Lung Disease, 2000, 4(2):123-132. Chee C. et al. Patient and disease characteristics, and outcome of treatment defaulters from the Singapore TB control unit -- a one-year retrospective survey. International Journal of Tuberculosis and Lung Disease, 2000,4(6):496-503. Diwan A., Thorson A. Sex, gender and tuberculosis. The Lancet, 1999, 353:1000-1001. Edginton M., Sekatane C., Goldstein S. Patients' beliefs: do they affect tuberculosis control? A study in a rural district of South Africa. International Journal of Tuberculosis and Lung Disease, 2002, 6(12):1057-1082. Evans T. et al. Challenging Inequalities in Health: From Ethics to Action. New York, Oxford University Press, 2001. Farmer, P . et al. Tuberculosis, poverty, and "compliance": lessons from rural Haiti. Seminars in Respiratory Infections, 1991, 6(4):254-60 Fryatt R. Review of published cost-effectiveness studies on tuberculosis treatment programmes. International Journal of Tuberculosis and Lung Disease, 1997, 1(2):101109. Godfrey-Faussett P . et al. Why do patients with a cough delay seeking care at Lusaka urban health centres? A health systems research approach. International Journal of Tuberculosis and Lung Disease, 2002, 6(9):796-805. Government of Mongolia. Economic Growth Support and Poverty Reduction Strategy. Ulaanbaatar, Government of Mongolia, 2003. Gwatkin D. Reaching the Poor. Presentation to the Asian Development Bank, Manila, 2003 (powerpoint presentation)

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Long N. et al. Fear and social isolation as consequences of tuberculosis in Viet Nam: a gender analysis. Health Policy, 2001, 58:69-81. Long N. et al. Longer delays in tuberculosis diagnosis among women in Vietnam. International Journal of Tuberculosis and Lung Disease, 1999a, 3(5):388-393. Long N. et al. Different tuberculosis in men and women: beliefs from focus groups in Vietnam. Social Science and Medicine, 1999b, 49(6):815-822. Lonnroth K. et al. Utilisation of private and public health-care providers for tuberculosis symptoms in Ho Chi Minh City, Viet Nam. Health Policy and Planning, 2001a, 16(1):47-54. Lonnroth K. et al. Can I afford treatment? Perceived consequences of health care provider choices among people with tuberculosis in Ho Chi Minh City, Viet Nam. Social Science and Medicine, 2001b, 52:935-948. Lui Y., Rao K., Hu S. People's Republic of China: Towards Establishing a Rural Health Protection System. Manila, Asian Development Bank, 2002. Lui Y., Hsiao W., Eggleston K. Equity in health and health care: the Chinese experience. Social Science and Medicine, 1999, 49(10):1349-1356. Mann G. et al. Expanding DOTS? Time for cost-effective diagnostic strategies for the poorest in Malawi. IUATLD Satellite Symposium, poster session and presentations. Montreal, 2002 (unpublished study). Ministry of Health of the People's Republic of China. Report on nationwide random survey for the epidemiology of tuberculosis in 2000. Beijing, Ministry of Health of the People's Republic of China, 2000. Ministry of Health of the People's Republic of China. Nationwide random survey for the epidemiology of tuberculosis in 1990. Beijing, Ministry of Public Health of the People's Republic of China, 1990. Nair D., George A., Chacko K. Tuberculosis in Bombay: new insights from poor urban patients. Health and Policy Planning, 1997, 12(1):77-85. Naranbat N. Description of risk factors for patients and doctors' delay of pulmonary smear positive tuberculosis in Mongolia, 2003 (unpublished document). Needham D. et al. Socio-economic, gender and health services factors affecting diagnostic delay for tuberculosis patients in urban Zambia. International Journal of Tuberculosis and Lung Disease, 2001, 6(4):256-259. Nhelma B. et al. A systematic analysis of TB and poverty. Geneva, Stop TB Partnership, World Health Organization, 2003. O'Boyle S. et al. Factors affecting patient compliance with anti-tuberculosis chemotherapy using the directly observed treatment, short-course strategy (DOTS). International Journal of Tuberculosis and Lung Disease, 2002, 6(4):307-312. Oxfam GB. Cambodia Land Study Project. Oxfam and the Ministry of Health of Cambodia, 2000. Patel V., Kleinman A. Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 2003, 81(8).

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4 5

8 9 10 11 12 13 14 15 16 17

20 21 22

23 24 25 26 27 28 29 30

31 32 33 34

35 36 37 38

World Bank 2001 WHO and World Bank 2001 Although it is challenging to create a comprehensive measure of poverty, the Human Development Index (HDI), developed by the United Nations Development Programme (UNDP), is an example of a concerted move forward. The HDI is grounded in the belief that poverty restricts people's freedom. Increasing freedom means ensuring people have the capacity to make decisions. The most basic human capabilities are good health, knowledge and access to resources. The HDI captures these elements by measuring three variables: life expectancy, educational attainment and income. UNDP 2003 World Bank 2003. The World Bank defines extreme poverty as US$ 1 a day, which is seen to be the minimum amount necessary for survival. Such income measures of poverty allow comparison between regions and countries. To calculate extreme poverty in a country, the dollar-a-day measure is converted to local currency using the purchasing power parity (PPP) exchange rate. The PPP is based on the relative prices of consumption goods in each country. UNDP 2003; Used by the World Bank, East Asia and the Pacific includes the following countries: Cambodia, China, Fiji, Indonesia, Kiribati, Korea, Republic of, Lao People's Democratic Republic, Malaysia, Marshall Islands, Micronesia, Federated States of, Mongolia, Myanmar, Palau, Papua New Guinea, Philippines, Samoa, Solomon Islands, Thailand, Timor-Leste, Tonga, Vanuatu, and Viet Nam Gwatkin, Guillot 2000. To calculate the burden of disease on the global poor, Gwatkin, Guillot disaggregate deaths from all causes into three principal disease groups: 1. communicable diseases, maternal and perinatal conditions, and nutritional deficiencies; 2. non-communicable diseases; and 3. accidents and injures. However, for ease of expression, the authors refer to group 1 conditions as communicable diseases. The discussion in this section follows their terminology. Gwatkin, Guillot 2000. Evans et al. 2001 Patel, Kleinman 2003 Evans et al. 2001 WHO 2001c WHO 2002 (unpublished) World Bank 2003 World Bank 2003 WHO 2001b Gross National Income (GNI) differs from Gross National Product (GDP) in that it also includes a terms of trade adjustment (http://www.worldbank.org/data/changinterm.html) Lower-middle-income countries have a GNI of $736 - $2,935. Considering a more comprehensive measure of poverty, the HDIs of the high burden countries rank low among countries that have achieved middle human development; UNDP 2003 Tupasi et al. 2000a. The prevalence rate of smear+ TB among urban poor and non-poor urban communities presented in Figure 5 are based on extrapolations from the observed population to the general population assuming the bacillary dieses is unlikely to occur in those younger than 10 years. Ministry of Health of China 2000 Xu et al. 2003 Thorson et al. 2003. Thorson et al. explain that 60% of male TB patients and 67% of female patients were from the lowest income quintile. In contrast, 18% of men and 22% of women in the general study population were from the lowest quintile. Nair et al. 1997 Tupasi et al. 2000b Rieder 1999, in Hanson 2002 Dallman 1987 Wilkinson et al. 2000 World Bank 1993 WHO 2001b WHO 2003a. In most countries, the male to female ratio of new sputum smear-positive cases is roughly 2:1 (WHO 2003c). See, for example, Borgdorff et al. 2000 See, for example, Huddleson 1996 and Uplekar et al. 1999 Holmes et al. 1998 Johansson et al. 2000. Specifically, Huddleson notes that the case fatality rate in women and girls between the ages of 5 24 years is 27-41% higher than in men Uplekar et al. 1999 WHO 2001d Viet Nam National TB Programme Review 2003 Thorson, Hoa, Long, 2000. The prevalence of long-term cough was found to be 1% in men and 2% in women. In another study in Viet Nam, Thorson et al. (2003) report that significantly more female TB cases were detected in a screening survey than in the NTP . The male-female ration in the screening survey was 0.8:1 verses 2.7:1 in the NTP . The authors estimate that the case detection rate among men TB patients is

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ENDNOTES

39 40

42 43 44

45 46 47 48 49 50 51

53 54 55 56 57 58

59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77

78 79 80 81 82 83 84 85 86

88 89 90 91 92 93 94

39% and a mere 12% for women TB patients. Thorson, Hoa, Long, 2000 Thorson, Hoa, Long, (2000) observe that the mean value per health care action was $4.99 for women and $9.07 for men, with a mean difference of $ 4.07. This is data was colleted in an area where the average monthly income was $11.03. Long et al. 1999b. On average, women experienced a delay of 5.4 weeks, while the delay for men was 3.8 weeks. Long et al. 1999a Long et al. 2002 Thorson, Hoa, Long, 2000. Thorson notes that sputum exams were only conducted in hospitals and only for 23% of TB cases Long et al. 2002 Long et al. 2002 Ministry of Health of China 2000 Mann et al. 2002 (unpublished) Kamolratanakul et al. 1999 Ramachandran et al. 1997 and Saunderson 1995, in Ahlburg 2000 In studies from India and Uganda, up to 80% of wage earners and 95% of subsistence farmers with TB experienced lower income resulting from decreased productivity and wage earning capacity. See Saunderson 1995, in Ahlburg 2000 and Nair et al. 1997 Schwenk, Macallan 2000, in Hanson 2002, explain that TB has been associated with reduced nutritional status including anemia, low plasma concentrations of retinal and zinc, and wasting. Ahlburg 2000 WHO and World Bank 2001 Ahlburg 2000 Kamolratanakul et al. 1999, and Rajasweri et al. 1999 Rajeshwari et al. 1999 Nhlema et al. 2003. In Lilongwe, Malawi, girls took on 28% of their mothers activities compared to 3% by boys (Mann et al. 2002 (unpublished)). Oxfam GB 2000 Long et al. 2001 Johansson et al. 2000 Nair et al. 1997 Ministry of Health of China 1990 Viet Nam National TB Programme Review 2003 http://www.who.int/gtb/policyrd/TBPrisons.htm Reynolds 2001 WHO 2001b Reynolds 2001 Ahlburg 2000 Roughly US$ 37.00 Portero, Rubio, Pasicatan, 2002 WHO 2001b WHO 2000 WHO 2001b Ministry of Health of China 2000 Fryatt 1997 Vassall et al. 2002. The World Bank recognises TB control using chemotherapy, as in DOTS, as one of the most cost-effective public health interventions (World Bank 1993). Danusantoso et al. 2002, in Nhlema et al. 2003 Gwatkin 2003 Kemp et al. 2001 (unpublished), in Nhlema et al. 2003 Nhlema et al. 2002 (unpublished), in Nhlema et al. 2003 Souza et al. 2000, in Nhlema et al. 2003 Ahlburg 2000 Karnolratanakul et al. 1999 Nhlema et al. 2003 Nhlema et al. 2003. Total delay, from the onset of the first disease symptom until the patient is diagnosed and starts treatment, can be broken down into: patient delay (from the onset of symptoms until a qualified medical practitioner is contacted) and provider delay (from the time of first visit to a health practitioner until the patient starts treatment). Johansson et al. 1996, Barnhoorn, Adriaanse 1992, Farmer et al. 1991, in Nhlema et al. 2003, and Edginton 2002 Lienhardt et al. 2001 Needham et al. 2001 Wandwalo and Morkve 2000 Lonnroth et al. 2001a Lienhardt et al. 2001 Wandwalo, Morkve 2000 Xu et al. 2003 (unpublished)

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95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134

135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154

Liendhart et al. 2001 Needham et al. 2001 Lienhardt et al. 2001 Wandwalo, Morkve 2000 Naranbat 2003 (unpublished) Portero, Rubio, Pasicatan 2002 Auer et al. 2000. See also Nair et al. 1997 on how TB is perceived by TB patients in Bombay Naranbat 2003 (unpublished) Dick et al. 1996, in Tupasi et al. 2000a Auer et al. 2000 Uplekar et al. 1999 Nichter 1994, in Long et al. 2001 Johansson et al. 1996 Auer et al. 2000 Uplekar et al. 1999 Smith 1994 (unpublished), in Hanson 2002 Johansson et al. 2000 Liefooghe et al. 1999 Johansson et al. 1996 Khan et al. 2000 Lonnroth et al. 2001b Balasubramanian, Oommen, Samuel 2000 Uplekar et al. 1999 Lonnroth et al. 2001a Long et al. 1999b and Johansson et al. 2000 Chee et al. 2000 Auer et al. 2000 For example, see Lonnroth et al. 2001b Mann et al. 2003 (unpublished) Johansson et al. 1996 Barnhoorn, Adriaanse 1992 Farmer et al. 1991 Edginton, Sekatane, Goldstein 2002 Khan et al. 2000 O'Boyle et al. 2002 Johansson et al. 1996 Viet Nam National TB Programme Review 2003 Uplekar et al. 1999 Uplekar et al. 1999 For example, Ensor, San 1996, Bloom 1998, and Gertler, Litvack 1998, in Lonnroth et al. 2001a explain that the introduction of user fees has increased inequity in general access to health care in Viet Nam Godfrey-Faussett et al. 2000 Long et al. 2001 Uplekar et al. 1999 Auer et al. 2000 Singh et al. 2002 Auer et al. 2000 Portero, Rubio, Pasicatan 2002 Lonnroth et al. 2001a Singh et al. 2002 Thorson, Hoa, Long 2000 Long et al. 1999b Thorson, Hoa, Long 2000 Portero, Rubio 2003 Tupasi et al. 2000a Lonnroth et al. 2001a Khan et al. 2000 Uplekar et al. 1999 Lonnroth et al. 2001a Lonnroth et al. 2001a Lonnroth et al. 2001a

CHALLENGES FOR TB PROGRAMMES IN THE WESTERN PACIFIC REGION

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Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 31 décembre 2004

Source Organisation mondiale de la santé