How affordable is <scp>TB</scp> care? Findings from a nationwide <scp>TB</scp> patient cost survey in Ghana

Pedrazzoli, Debora; Siroka, Andrew; Boccia, Delia; Bonsu, Frank; Nartey, Kenneth; Houben, Rein M. G. J.; Borghi, Josephine

doi:10.1111/tmi.13085

Cited by 60 publications

(69 citation statements)

References 29 publications

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“…Many low-and middle-income countries (including China) aim to provide TB diagnosis and treatment free of charge, however, direct and indirect costs due to TB continue accounting for a high proportion of annual household income of TB patients [8,13,14]. In the past, China has received substantial international assistance in the fight against TB, but now it is essential to mobilize increased domestic resources to improve the accessibility and affordability of high quality TB care.…”

Section: Discussionmentioning

confidence: 99%

A New Financing Model for Tuberculosis (TB) Care in China: Challenges of Policy Development and Lessons Learned from the Implementation

Long

Jiang

Dong

et al. 2020

IJERPH

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Background: With support from the Gates Foundation, the Chinese Center for Disease Control and Prevention (China CDC) introduced a new financing model for tuberculosis (TB) care. This paper reviews the development of the associated financing policies and payment methods in three project sites and analyzes the factors impacting on policy implementation and outcomes. Methods: We reviewed policy papers and other relevant documents issued in the project sites. Semi-structured qualitative interviews were conducted with key stakeholders at provincial, city and county levels. Thematic analysis was applied to identify themes and develop interpretations. Results: The China CDC guideline proposed the introduction of a case-based payment based on TB treatment clinical pathways, increased reimbursement rates and financial assistance for the poorest TB patients. Contrary to expectations, TB patients with complications and/or comorbidities were often excluded from the program by hospitals that were concerned the cost of care would exceed the case-based payment ceiling. In addition, doctors frequently prescribed services and/or drugs beyond the coverage of the benefit package for those in the program. Consequently, actual reimbursement rates were low and poor patients still faced a heavy financial burden, though the utilization of services increased, especially by poorer patients. Qualitative interviews revealed three main factors affecting payment policy implementation. They were: hospital managers’ concern on the potential for reduced revenue generation; their fear that patients would regard the service provided as sub-standard if they were not prescribed the full range of available treatments; and a lack of mechanisms to effectively monitor and support the implementation process. Conclusions: While the intervention had some success in improving access to TB care, the challenges of implementing the policy in what proved to be an unreceptive and often antagonistic context resulted in divergences from the original design that frustrated its aim of reducing the financial burden on patients.

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Section: Discussionmentioning

confidence: 99%

A New Financing Model for Tuberculosis (TB) Care in China: Challenges of Policy Development and Lessons Learned from the Implementation

Long

Jiang

Dong

et al. 2020

IJERPH

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“…This is witnessed by the low TB burden in countries with high social protection and vice-versa [3]. Evidence from several countries including India shows that TB causes catastrophic economic effects on the patients and their households [4][5][6][7][8][9][10]. Ensuring that no TBaffected families face catastrophic expenditure by 2020 is one of the goals of the END TB strategy of the World Health Organization (WHO) [11].…”

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confidence: 99%

‘I am on treatment since 5 months but I have not received any money’: coverage, delays and implementation challenges of ‘Direct Benefit Transfer’ for tuberculosis patients – a mixed-methods study from South India

Nirgude

Kumar

Timire

et al. 2019

Global Health Action

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Background : In March 2018, the Government of India launched a direct benefit transfer (DBT) scheme to provide nutritional support for all tuberculosis (TB) patients in line with END TB strategy. Here, the money (@INR 500 [~8 USD] per month) is deposited electronically into the bank accounts of beneficiaries. To avail the benefit, patients are to be notified in NIKSHAY (web-based notification portal of India’s national TB programme) and provide bank account details. Once these details are entered into NIKSHAY, checked and approved by the TB programme officials, it is sent to the public financial management system (PFMS) portal for further processing and payment. Objectives : To assess the coverage and implementation barriers of DBT among TB patients notified during April–June 2018 and residing in Dakshina Kannada, a district in South India. Methods : This was a convergent mixed-methods study involving cohort analysis of patient data from NIKSHAY and thematic analysis of in-depth interviews of providers and patients. Results : Of 417 patients, 208 (49.9%) received approvals for payment by PFMS and 119 (28.7%) got paid by 1 December 2018 (censor date). Reasons for not receiving DBT included (i) not having a bank account especially among migrant labourers in urban areas, (ii) refusal to avail DBT by rich patients and those with confidentiality concerns, (iii) lack of knowledge and (iv) perception that money was too little to meet the needs. The median (IQR) delay from diagnosis to payment was 101 (67–173) days. Delays were related to the complexity of processes requiring multiple layers of approval and paper-based documentation which overburdened the staff, bulk processing once-a-month and technological challenges (poor connectivity and issues related to NIKSHAY and PFMS portals). Conclusion : DBT coverage was low and there were substantial delays. Implementation barriers need to be addressed urgently to improve uptake and efficiency. The TB programme has begun to take action.

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“…Also, in our context even DS-TB patients experienced higher catastrophic costs than overall costs reported from other low-and middle income countries. (8,9,12,13) High catastrophic costs may negatively impact on both access and adherence to TB treatment.…”

Section: Discussionmentioning

confidence: 99%

“…Despite interventions aimed at cushioning TB patients against direct medical costs, surveys in Africa and Asia have shown high prevalence of catastrophic costs especially among i) drug resistant TB (DR-TB) patients, ii) poorest households, iii) cases where the patients were breadwinners and iv) those co-infected with HIV. (8,9,(11)(12)(13) In 2016, Zimbabwe embraced the End TB targets of eliminating catastrophic costs by 2020. The national TB control programme (NTP) has decentralised TB services, provided cash transfers to DR-TB patients and adopted active case nding to detect TB cases early.…”

Section: Introductionmentioning

confidence: 99%

Catastrophic costs among tuberculosis patients in Zimbabwe: a national health facility-based survey

Timire¹,

Ngwenya²,

Chirenda³

et al. 2020

Preprint

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Background: Tuberculosis (TB) has biological and socio-economic dimensions. The socio-economic impact of TB may plunge households into financial catastrophes. The End TB strategy seeks to mitigate socio-economic factors which may act as barriers to accessing TB services. Countries have been encouraged to provide baseline estimates of catastrophic costs by 2020. We sought to determine the prevalence, risk factors and major drivers of catastrophic costs among TB patients in Zimbabwe. Methods: We conducted a nationally representative, health facility-based survey with random cluster sampling among TB patients. We enrolled patients with drug susceptible (DS-TB) and drug resistant TB (DR-TB) consecutively. We administered a standardised questionnaire to capture the costs incurred as well as lost income due to TB illness. Catastrophic costs were measured at a threshold of 20%. We did a sensitivity analysis of indirect costs using the time lost by patients in each phase of treatment. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs. Results: A total of 841 patients were enrolled in the survey, weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI:77-82%) of TB patients and their households experienced catastrophic costs. The major cost drivers pre-TB diagnosis were direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, (median cost US$360 (IQR: 240-600). Post-TB diagnosis costs were three-times higher among DR-TB [US$1,659 (653-2,787)] versus drug susceptible TB (DS-TB) affected households [US$537 (204-1,134)]. Income loss was five-times higher among DR-TB versus DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: the poorest households had sixteen times the odds of incurring catastrophic costs compared to wealthiest households [adjusted odds ratio (aOR:15.7 95% CI:7.5-33.1)]. Conclusion: The majority of TB patients enrolled in care experienced catastrophic costs, with the highest burden on DR-TB patients. Since the major cost drivers fall outside the healthcare system, a multi-sectoral approach to TB control and linking TB patients to social protection schemes holds promise for reducing catastrophic costs in Zimbabwe.

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How affordable is TB care? Findings from a nationwide TB patient cost survey in Ghana

Abstract: TB patients in Ghana incur substantial costs, despite free diagnosis and treatment. High rates of catastrophic costs and coping strategies in both non-MDR and MDR patients show that new policies are urgently needed to ensure TB care is actually affordable for TB patients.

Cited by 60 publications

References 29 publications

A New Financing Model for Tuberculosis (TB) Care in China: Challenges of Policy Development and Lessons Learned from the Implementation

A New Financing Model for Tuberculosis (TB) Care in China: Challenges of Policy Development and Lessons Learned from the Implementation

‘I am on treatment since 5 months but I have not received any money’: coverage, delays and implementation challenges of ‘Direct Benefit Transfer’ for tuberculosis patients – a mixed-methods study from South India

Catastrophic costs among tuberculosis patients in Zimbabwe: a national health facility-based survey

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