Transcript Parliamentarians as a Voice for the Poor

Poverty & TB: Global Overview
and Kenyan case study
Christy Hanson, PhD, MPH
PATH
May 30, 2005
CCIH Annual Conference
Global TB Control: TB facts
TB is infectious, curable disease
 8.8 million new cases of TB in 2003
 TB is the primary cause of death for
PLWHA in Africa
 Highly cost-effective treatment
strategy
 Only half of new cases were detected
in 2003

Estimated TB incidence rates
2003
per 100 000 population
< 10
10 to 24
25 to 49
50 to 99
100 to 299
300 or more
No Estimate
TB and HIV: Overlapping epidemics
TB infected
(1.7 billion)
Active
TB (8.8 m per year)
HIV at risk (?)
HIV (+) with
Active TB (0.7 m)
HIV (+)
(40 m)
Estimated HIV Prevalence in TB cases, 2002
HIV prevalence in TB
cases, 15-49 yrs (%)
<5
5 - 19
20 - 49
50 or more
No estimate
Global Tuberculosis Control. WHO Report 2003. WHO/HTM/TB/2004.331
Africa: HIV driving the TB epidemic
TB notification rates, 1980-2003
400
300
200
100
9
2 8
0
0
2
5
Tanzania
2
Malawi
9
9
8
6
Kenya
9
Côte d'Ivoire
8
3
8
0
0
8
Source: WHO reports
Rate (x100,000)
500
Zimbabwe
TB incidence
700
0.16
0.14
0.12
0.10
0.08
0.06
0.04
0.02
0.00
600
500
400
300
200
100
0
1980
1990
2000
2010
HIV prevalence
TB and HIV in Kenya
Global Targets for TB control

70% case detection

85% treatment success
TB can be cured: DOTS
strategy
Political commitment
 Standardized treatment regimen


Available free of charge to patients in
public sector
Diagnosis by smear microscopy
 Directly-observed treatment (DOT)
 Standardized recording and
reporting


Quality control
DOTS Works

China
DOTS areas: 44% decrease in TB
prevalence (1990-2000)
 Non-DOTS areas: 12% decrease in TB
prevalence


Global level
DOTS areas: treatment success rates
average 80%
 Non-DOTS areas: around 50%

Evolution of DOTS
1995
Adopting DOTS
2005
Expanding DOTS
Adapting DOTS
Number of countries implementing
DOTS, 1990 - 2003
Number of countries
Total number of countries
200
150
100
50
0
1990 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003
Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295
Challenges for the future of
TB control

Dual epidemic of TB/HIV

Low case detection rates
Possible cause: not reaching the poor?
Poverty:
Inequity between countries
Distribution of Poverty
Distribution of population living on less
than $1 a day, 1998 (1.2 billion)
Europe &
Central Asia
2%
Latin America
& Caribbean
7%
East Asia &
Pacific
23%
Sub-Saharan
Africa
24%
Middle East &
North Africa
1%
South Asia
43%
Source: World Bank, WDR 2000
Causes of Poor-Rich
Health Status Gap
Source: World Bank; Gwatkin, D.; 2000
1990 Deaths
Injuries
8%
Non-Communicable
Diseases – 15%
Communicable Diseases
77%
* “poor” and “rich” represent poorest countries / richest countries
Source: World Bank; Gwatkin, D.; 2000
Disproportionate disease
burden among the poor*
70
60
50
40
30
20
10
0
Poorest 20%
Richest 20%
% of all
% of DALYs
deaths due to lost to TB
TB
* “poor” and “rich” represent poorest countries / richest countries
22 Highest TB burden
countries

None are high-income countries

78% have GNP per capita of less
than $760 (low income)

Estimate: over 50% new TB patients
without access to DOTS are living on
less than $2 per day
Korea case study
TB And Economic Development
10000
Per capita GNI
350
TB cases
100
49
10
TB deaths
Korean War
Rates per 100,000
1000
7
NTP
Unemployment rates
1
1948
1950
1955
1960
1965
1970
1975
Year
1980
1985
1990
1995
2000
Poverty:
Inequity within countries
TB prevalence among poor
and non-poor, Philippines
6
5
4
Sm+ TB
rate per 3
1000
2
1
0
National
Urban
non-poor
Source: Tupasi et. al.; IJTLD 4(12): 1126-1132
Urban
poor
TB and poverty: correlation in a
high-income country
Average Case Rate
70
per 100,000
60
50
40
30
20
10
0
East End, London
England & Wales
San Francisco homeless: TB cases 1992-1996
500
400
300
200
100
0
* Notified cases
Af
ric
an
W
Ot
hi
he
te
rn
on
Am
-w
er
hi
ica
te
ns
Bo
ts
w
an
a*
(1
99
7)
Source: Moss, Hahn, Tulsky et al.; Am J Respir Crit Care Med 2000
TB in the homeless
Poverty:
Individual level
TB Epidemiology
Risk
factors
Risk
factors
Risk
factors
Risk
factors
Infectious
TB
Exposure
Sub-clinical
infection
Cure,
chronic or
Death
Non-infectious
TB
Source: adapted from Urban & Vogel; Am Rev Respir Dis 1981
Income poverty and TB
The poor lack:
•Food security
•Income stability
•Access to water, sanitation
•Access to health care
Income poverty
TB disease
TB may lead to:
•Loss of 20-30% of annual wages among poor
Poverty links to TB exposure,
infection and disease
Overcrowding
 Malnutrition




Gender differentials



TB
anemia, low retinol & zinc, wasting
Vit D deficiency
10x risk of TB disease
Higher prevalence among men
Women:faster breakdown to TB disease (2x)
Marginalized populations


Ethnicity
Prisoners
TB cases per 100,000
person-years
TB case rates by SES indicator:
United States 1987-1993
50
40
Crowding
30
Income
20
Poverty
Unemployment
10
Education
0
Decreasing SES
Source: Cantwell, McKenna, McCray, et al.; Am J Respir Crit Care Med, 1998
Poverty & TB disease outcome

Impoverishing effects of TB





Economic: 20-30% of household wages
Social: stigma
Women fear social impoverishment, men fear
economic
Delayed treatment seeking
Worse outcomes?



Barriers to access
Inhibited continuity
In absence of treatment, 50% will die
Reasons for treatment
delay: China
Inaccessible
health
providers
10%
Others
12%
Financial
45%
Source: Ministry of Health, China; 1990 prevalence survey
Perception
of illness
23%
Not
informed
10%
Global Response to Health
Inequities

Millennium Development Goals


Poverty-Reduction Strategy Papers



Halve the prevalence of TB disease and
deaths between 1990 and 2015
Re-orienting development agenda toward propoor approaches
Debt-relief, increased funds for social sectors
Global Fund for AIDS, TB and malaria

4 rounds of applications funded
• over $8 billion approved

$1 billion for TB (13%)
Can we meet the MDGs?
1.6
1.4
1.2
incidence
prevalence
death
1.0
0.8
0.6
2015 =1990
MDG
Eu
ro
pe
E
M
ed
L
Am
er
ica
SE
As
ia
W
Pa
cif
ic
W
or
ld
E
lo
w
Af
ric
a
hi
gh
0.4
0.2
0.0
Af
ric
a
2015/1990 values
With current plan 2006-15, not in Africa
Financing public health:
caring for the poor?
Financial subsidy from Government
health services to poorest & richest 20%
Regional averages
30
25
20
% 15
10
5
0
Africa
Asia
Poorest 20%
Source: World Bank, 2001
E Europe
Richest 20%
Latin Am
Expenditures on TB care by
level of wealth
Sample of patients in Nairobi
40
35
30
Average total
expenditure on
care seeking for
TB illness (US$)
Ratio of average
expenditure to
wealth score
25
20
15
10
5
0
Poorest
Source: Hanson and Kutwa (unpublished)
Relatively
rich
Mounting a response
TB community response to
TB and poverty

DOTS expansion and adaptation

Global TB Drug Facility

Stop TB Partnership

Collaboration with NGOs, partners

Social and resource mobilization
• 2002 Theme: TB and poverty

Research

Benefit - incidence

Evaluating what works

Understanding what matters to the poor (demand)
Addressing barriers to care:
Examples
Cambodia: food incentives for all
TB patients
 Uganda: community-based care
 China: increased financing for TB
control in poorest areas
 Kenya: mobile treatment facilities
for migrant populations
 Mauritania: salary supplements for
health workers in poor, rural areas

Kenyan Case Study
Is the health system
responding to
poverty dimension
of TB?
Trends in Tuberculosis: Kenya
Infectious (smear+) cases of TB
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
•46% of population
lives in absolute
poverty
•>50% of TB patients
are HIV+
1995
1997
1999
2002
2003
Estimated sm+ cases (incidence)
Source: WHO reports: 1997, 1998, 1999, 2000,2001, 2002, 2003, 2004, 2005
Sm+ cases detected
Evidence of link: TB
incidence and poverty
TB case finding
(per 100,000)
Variance in case notifications by province
500
100
400
80
300
60
200
40
100
20
0
0
0
20
40
60
Prevalence of hardcore poverty
Evidence of link: TB
incidence and poverty
500
100
400
80
300
60
200
40
100
20
0
0
0
20
40
60
Prevalence of hardcore poverty
% of children
immunized with
DPT3 and polio
TB case finding
(per 100,000)
Variance in case notifications by province
Study objectives

Current performance of health sector in
reaching poor TB patients

Treatment seeking patterns of poor vs.
non-poor

Identify provider and patient
characteristics associated with utilization
of DOTS providers
Survey Tools
n=3500


Provider: costs, services, patient base
Individual
 Demographic information
 Health information
• Symptoms, choice set


TB knowledge
Treatment-seeking behavior
• Movement between formal, informal, private, public
• Utilization and expenditures

Valuation
• Inventory what is important in decision-making
• Preferences
Mean wealth of TB
patients completing
treatment
Wealth of TB patients &
poverty in their provinces
5
4
3
2
1
0
0
10
20
30
40
Prevalence of hardcore poverty
50
Profile of TB patients treated
in public and private sectors
% of all patients
3% of patients completing treatment are among the poorest
60
50
40
30
20
10
0
ea
W
4
Q
3
Q
e
hi
lt
st
re
oo
2
Q
P
st
Public sector: initiating tx
Public sector: completing tx
Private sector: initiating tx
Private sector: completing tx
Change in wealth profile along
continuum of diagnosis & treatment
Most poor
Least poor
Nyeri
Diagnosis
Treatment completion
Where patients go vs.
Where the system provides DOTS
Percent of all public facilities that
participate in DOTS implementation
Health facilities by type,2001
Health clinic
13%
Nursing
home
4%
100
80
60
40
20
Hospital
10%
Health
centre
12%
0
Hospital
Health centre
Dispensary
First interaction with health system: poor
Dispensary
61%
25
20
15
10
5
0
dispensary
health centre
public
hospital
private
pharmacy
Movement through the health
system: the case of the poor

40% start at decentralized dispensaries

Start at hospital level, 12% transition “backwards”

Less efficient transitioning
• More visits (half had 5-10 visits, still not referred for dx)
• More time ill
• Higher expenditures

Most interact with a “DOTS” facility within 1st three
visits, still don’t get referred for diagnosis
• Individual & provider factors behind transitioning
Conclusions & Next steps


TB patients actively seeking care
Poor disproportionately represented at all stages



Research: prevalence distribution by wealth
Social science research: why?
Private sector: competitive, well used

Cost & geographic access similar

District variance: lessons to be learned from
successful districts

Modeling of system and district-level
determinants impacting case detection
New initiatives: test strategies to reach the poor

Conclusions





TB disproportionately affects the poorest
countries & poorest populations
TB has impoverishing effects on
individuals and households
TB can be cured
DOTS is cost-effective and adaptable to
become pro-poor
Equity approach to the expansion of
DOTS needed


Attain global targets
Serve local populations
Voices of the poor: Can
anyone hear us?
“The authorities don’t
seem to see poor
people. Everything
about the poor is
despised, and above
all, poverty is
despised.”
- Brazil, 1995