Poverty

1
Poverty TB Global Overview and Kenyan case
study

• Christy Hanson, PhD, MPH
• PATH
• May 30, 2005
• CCIH Annual Conference

2
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

3
Estimated TB incidence rates 2003
4
TB and HIV Overlapping epidemics
TB infected (1.7 billion)
HIV at risk (?)
HIV () (40 m)
Active TB (8.8 m per year)
HIV () with Active TB (0.7 m)
5
Estimated HIV Prevalence in TB cases, 2002
Global Tuberculosis Control. WHO Report 2003.
WHO/HTM/TB/2004.331
6
Africa HIV driving the TB epidemicTB
notification rates, 1980-2003
Source WHO reports
7
TB and HIV in Kenya
HIV prevalence
TB incidence
8
Global Targets for TB control

• 70 case detection
• 85 treatment success

9
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

10
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

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Evolution of DOTS
Broaden ownership private sector, partners
Emerging threats TB/HIV, MDR-TB
Building political commitment
New tools diagnostics, drugs
Increase case detection
Resource mobilization
Widescale training
Health sector reform
Adoption of DOTS
DOTS brand
Model developed in Africa Karel Styblo
1995
2005
Adopting DOTS
Expanding DOTS
Adapting DOTS
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Number of countries implementing DOTS, 1990 - 2003
Total number of countries
200
150
Number of countries
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
13
Challenges for the future of TB control

• Dual epidemic of TB/HIV
• Low case detection rates

Possible cause not reaching the poor?
14
Poverty Inequity between countries
15
Distribution of Poverty
Source World Bank, WDR 2000
16
Causes of Poor-Rich Health Status Gap
Non-Communicable Diseases 15
Injuries 8
Source World Bank Gwatkin, D. 2000
Communicable Diseases 77
poor and rich represent poorest countries /
richest countries
17
Disproportionate disease burden among the poor
Source World Bank Gwatkin, D. 2000
poor and rich represent poorest countries /
richest countries
18
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

19
Korea case study
TB And Economic Development
Per capita GNI
350
TB cases
Korean War
49
TB deaths
7
NTP
Unemployment rates
20
Poverty Inequity within countries
21
TB prevalence among poor and non-poor, Philippines
Source Tupasi et. al. IJTLD 4(12) 1126-1132
22
TB and poverty correlation in a high-income
country
23
TB in the homeless
Source Moss, Hahn, Tulsky et al. Am J Respir
Crit Care Med 2000
Annual incidence per 100,000
Notified cases
24
Poverty Individual level
25
TB Epidemiology
Infectious TB
Sub-clinical infection
Cure, chronic or Death
Exposure
Non-infectious TB
Source adapted from Urban Vogel Am Rev Respir
Dis 1981
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Income poverty and TB

• The poor lack
• Food security
• Income stability
• Access to water, sanitation
• Access to health care

TB disease
Income poverty

• TB may lead to
• Loss of 20-30 of annual wages among poor

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Poverty links to TB exposure, infection and
disease

• Overcrowding
• Malnutrition
• TB anemia, low retinol zinc, wasting
• Vit D deficiency 10x risk of TB disease
• Gender differentials
• Higher prevalence among men
• Womenfaster breakdown to TB disease (2x)
• Marginalized populations
• Ethnicity
• Prisoners

28
TB case rates by SES indicator United States
1987-1993
Source Cantwell, McKenna, McCray, et al. Am J
Respir Crit Care Med, 1998
29
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

30
Reasons for treatment delay China
Source Ministry of Health, China 1990
prevalence survey
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Global Response to Health Inequities

• Millennium Development Goals
• Halve the prevalence of TB disease and deaths
  between 1990 and 2015
• Poverty-Reduction Strategy Papers
• Re-orienting development agenda toward pro-poor
  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)

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(No Transcript)
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Financing public health caring for the poor?
34
Financial subsidy from Government health services
to poorest richest 20
Source World Bank, 2001
35
Expenditures on TB care by level of wealth
Sample of patients in Nairobi
US
Source Hanson and Kutwa (unpublished)
36
Mounting a response
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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)

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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

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Kenyan Case Study

• Is the health system responding to poverty
  dimension of TB?

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Trends in Tuberculosis Kenya

• 46 of population lives in absolute poverty
• gt50 of TB patients are HIV

Source WHO reports 1997, 1998, 1999, 2000,2001,
2002, 2003, 2004, 2005
41
Evidence of link TB incidence and poverty
42
Evidence of link TB incidence and poverty
43
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

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Survey Tools
n3500

• 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

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Wealth of TB patients poverty in their provinces
46
Profile of TB patients treated in public and
private sectors
3 of patients completing treatment are among the
poorest
47
Change in wealth profile along continuum of
diagnosis treatment
Most poor Least poor
Diagnosis Treatment completion
48
Where patients go vs. Where the system provides
DOTS
49
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 dont get referred for
  diagnosis
• Individual provider factors behind
  transitioning

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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

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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

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Voices of the poor Can anyone hear us?

• The authorities dont seem to see poor people.
  Everything about the poor is despised, and above
  all, poverty is despised.
• - Brazil, 1995