Transcript Access to health care for TB patients: Mapping patients’ costs

Access to health care for TB patients:
Mapping patients’ costs
by Verena Mauch
What are important issues in access to
health care for TB patients?
•
TB affects especially the poor.
•
Economically and socially disadvantaged groups
face barriers when seeking treatment.
•
TB can stand at the beginning of a spiral into
(deeper) poverty.
•
By addressing barriers and reasons for delay to
timely diagnosis and treatment by NTPs, costs to TB
patients can be reduced.
•
The Tool To Estimate Patients’ Costs can assist TB
programs in identifying these barriers.
What are the types of costs that TB patients face?
Charges for health services
Lost income, productivity, time
Transport, accommodation, subsistence
What is The Tool to Estimate Patients’ Costs?
A generic questionnaire to be adapted to local
circumstances, accompanied by guidelines and
work-aids:
• literature review
• socioeconomic indicators guide
• list of indicators to be measured with the Tool
• guidelines on adaptation of questionnaire, methods
sampling, interpretation of results, possible
interventions
• template for data entry, summary calculation sheet,
example presentation of results
Example page
of generic
questionnaire
What are the aims of the Tool?
1. Assess the impact of TB on the welfare of households
and individuals.
2. Establish an evidence base for interventions that can
 contribute to poverty reduction
 increase equity in access to care
 increase case detection
 contribute to improved treatment adherence
How does it work?
The questionnaire helps to collect information on:
• Direct (out of pocket) and indirect (opportunity) costs of
TB patients before/during diagnosis & during treatment
• Costs of a patient’s supporter (guardian)
• Health-care seeking behavior patterns incl private sector
• Patient & health system delays
• Changes in patient’s productivity due to TB
• Additional costs due to other chronic illnesses (HIV)
…
How does it work?
• Coping costs
– sale of assets, taking up debt
– saving on food and other items
– taking a child out of school to care for the patient
• Health insurance
• Gender issues and social costs of TB
• Socioeconomic information
• Personal and household income
• Asset index and food consumption as proxies for income
Example: Tool Pilot in Kenya
• By Kenya NTP (DLTLD) and KNCV
• In two districts in Eastern Province (population ~760.700)
• 208 TB patients >15 years interviewed in 9 facilities
• Questionnaire adapted and translated into Kiswahili and
back into English to ensure cross-validity
• One interview lasted on average 30-45 minutes
Time
• Preparation, protocol development, ethics approval:
July – August 2008
• Interviews and data entry: September 2008
• Data analysis and report writing: October 2008
Tool pilot in Kenya - Results Example 1
Patients’costs
Patients’ costs
before
before
and during
and during
diagnosis
diagnosis
by NTP
Direct cost: 1.592 KSH (median 860) = US$21(10)
Time spent: 24 hours (median 12)
Number of visits: 3,4 (median 3)
Patient Delay: 1,5 – 2,9 months
Results Example 2
Total direct and indirect costs as proportion of personal income
Direct costs = out of pocket costs
Indirect costs = opportunity costs
Results Example 3
Changes in income of households and individuals due to TB
Feasibility of implementing the Tool
• Can be done by Master-level students (Kenya,
Myanmar), NTPs (Viet Nam), NGOs (Dom Rep)
• Background in social sciences helpful, but not required
• Data analysis: simple descriptive stats & crosstabs
• Software required: Word, Statistics Program
• Time required: 3-4 months with one full-time staff
• Costs: depending on local prices and seniority of staff
US$10.000 – 35.000.
Limitations of the Tool
• Only those are captured who reached a health facility
which provides DOTS.
• Bias towards those who can afford health care.
• Depending on place of the interview, automatically a
certain group of patients is excluded
• Results heavily dependent on area/district where patients
are interviewed.
• Recall and response bias.
• Unreliability of income data.
Impact of the pilot
• Evaluated through follow up interviews with key staff
and stakeholders six months after the pilot.
In the pilot districts:
• Decentralization of treatment services
• Nutritional support for TB patients
• Sputum sample transport to diagnostic centres
On national level:
• TB & poverty/gender working group
Where is the Tool available ?
Currently implemented in Ghana, Dominican Republic
and Viet Nam.
Available on websites (free access):
TB & Poverty Working Group
www.stoptb.org/tbandpoverty
TB Coalition for Technical Assistance
www.tbcta.org
Or contact KNCV TB Foundation
www.kncvtbc.nl
Thank you!
Acknowledgements
Tuberculosis Coalition for Technical Assistance TBCTA
Tuberculosis Control Assistance Program TBCAP
United States Agency for International Development USAID
WHO Stop TB Department
Japan Anti-Tuberculosis Association JATA
Kenya Ministry of Public Health and Sanitation: Division of
Leprosy, Tuberculosis and Lung Disease DLTLD
Naomi Woods, Merlin, Goma, DR Congo
Beatrice Kirubi, KEMRI Centre for Public Health Research,
Nairobi, Kenya
Members of the TB & Poverty Working Group