Eliminating catastrophic burden on Tuberculosis Kenyan ...

Susan Gacheri ( MPH )

DLTLD, MOPHS

Eliminating catastrophic burden on Tuberculosis

Kenyan experience

Brazil

29th April- 2nd May 2013

Outline

• Background information

• Challenges/Gaps

• Interventions

• Action points

To render Kenya and its communities free of Leprosy, TB and Lung

Disease

Introduction

• Population: 40 million

• Recurrent Health sector-9%

• GDP per capita US$328

• 15th among the 22 high TB burden

countries

• 2012: TB case notification 102,009

• HIV prevalence - 6.4% (15-49 yrs )

(KDHS 2008/9)

• An estimated no of PLHIVs-1.5M

• 2012: PLHIV on care – 867,000

including 60,0000 children

• 2012: HIV co-infection among TB

patients - 37%

Introduction

Trend of TB case notifications: 1987-

2011

1. Core TB Case Detection &

Management

2. Laboratory

3. Logistics and commodities

4. TB/HIV

5. MDR TB

6. Childhood TB

7. Special Groups

8. Health system

Strengthening and Human

Resources

9. Lung Health

10. PPM

11. Health promotion

12. Community based TB care

13. Poverty and Gender

14. Leprosy

15. M & E and operations

research

DLTLD strategic plan thematic areas:

2011-2015

• HIV Epidemic (prevalence of 6.4% -2008)

• Poverty: High levels of poverty- 45.9% of the population live

below the poverty line (WB report 2011).

• Overcrowding and poor housing

• Chronic food insecure - 5% of pop

• High malnutrition (48%) among TB patients

• Disparities in access to health care among different groups of

people based on their socio-economic status, gender as well as

age

To render Kenya and its communities free of Leprosy, TB and Lung Disease

Key challenges to TB control in Kenya

Social cultural and economic barriers:

• QUOTE study- 2004

• Cost tool study-2008

• FGD on TB, Poverty & Gender- 2011

• Nutrition assessment among TB Patients-2012

• National report-DLTLD 2012

To render Kenya and its communities free of Leprosy, TB and Lung Disease

Barriers hindering optimal TB care and services

TB Patient Socioeconomic Status

(cost tool study)

13%

28%

15% 5%

39% 10000 - 20000

5000 - 10000

Didn't earn

Over 20000

Under 5000

Patient Cost before

treatment

Transport, diagnostic tests (x-ray)

and food are the biggest cost items

before and during diagnosis(cost

study)

Transport 38%

Tests 37%

Food 19%

Administration 6%

Pre Diagnosis costs

Patient Cost during

treatment

Transport and food are the

biggest cost item during

treatment.

Food, transport, counselling

and free diagnostic services are

the other kinds of support TB

patients need apart from free

drugs.

Patients reported that free food

would improve their

compliance rates, as it would

address the attendant hunger

occasioned by TB drugs.

45%

55%

Food

Transport

Indirect costs during treatment

Coping Costs

Borrowing behaviour and sale of

assets

0

20

40

60

80

0 < 5K 5K - 10K 10K -

20K

> 20K

Income bracket (KSH)

Bo

rro

wed

or

So

ld

(%)

Borrowed Money

Sold Assets

TB/HIV Costs

0

500

1000

1500

2000

2500

Pre-Diagnosis Treatment Coping

HIV+

Not HIV+

• Women spend more seeking

health services thought they

tend to have less economic

empowerment leading to

delay in seeking health care

as compared to male

• Alcoholism identified as a

common cause of male TB

patients defaulting from TB

treatment

0

100

200

300

400

500

600

700

800

Direct Indirect Total

Costs Incurred

% o

f m

on

th

ly in

co

me

Male

Female

Gender and treatment costs

• Social and cultural barriers:

– Stigma, gender-related factors, fear of losing work, lack of /

inadequate knowledge of TB, mis-conceptions about TB.

• Health system barriers:

– lnadequate health system responsiveness to TB issues

– lnadequate health facilities, Long distances to facilities

– Understaffing - staff overwhelmed with work

• Quality of TB services

• Attitude issues To render Kenya and its communities free of Leprosy, TB and Lung Disease

Barriers cont’d

Initiatives/programs

To render Kenya and its communities free of Leprosy, TB and Lung Disease

• Increase screening of

TB/HIV during field

activities

• Services to ensure that

clients receive HAART,

TB treatment and IPT

• Interaction between the

TB, HIV and other

programs for

comprehensive care

Integration of services

TB-HIV activities

• Decentralization of TB treatment diagnostic services

• Patient support(enablers and incentives) program: Food

support, Baseline and follow up investigations and

transport support-limited to only DR-TB patients

• TB control in congregate settings

• DR-TB, Drug resistance surveillance system

• Nutrition program

• Community based TB program

• ACSM

To render Kenya and its communities free of Leprosy, TB and Lung Disease

TB specific interventions

Improved Laboratory Services

73 75 77

65

77 79 80 80 79 80 80 82 85 85 85 86 87

0

10

20

30

40

50

60

70

80

90

100

19

94

'

19

95

'

19

96

'

19

97

'

19

98

'

19

99

'

20

00

'

20

01

'

20

02

'

20

03

'

20

04

'

20

05

'

20

06

'

20

07

'

20

08

'

20

09

'

20

10

'

Pe

rce

nta

ge

Year

TSR Died Linear (TSR)

Trend of Treatment Outcomes of New Smear

Positive TB patients :1994-2010

• New constitution-

• Right to health for all citizens

• Devolved government: County governments

• Vision 2030: Economic, Social & political pillar

• Social Protection Policy 2012

• Community Health strategy

• Civil Society Organization networks

To render Kenya and its communities free of Leprosy, TB and Lung Disease

Platforms for extension

• National Social Security Fund (NSSF)

• Civil Service Pension scheme

• Retirement benefit schemes

• National Hospital Insurance Fund (NHIF)

• Cash transfer programs

• Informal community support and extended families:

provide a significant form of social protection to

citizens To render Kenya and its communities free of Leprosy, TB and Lung Disease

Social protection schemes

• Community health strategy

launched (2006) to ensure

health services are delivered at

the door step

• Community units and

governance structures

established

• Goal: To Reverse the declining

trends of health indicators

• A policy on CSOs engagement

in TB,TB/HIV in place (2012)

Community engagement in health

• Include SP (TB) in National health strategic plans

• Expand the coverage of TB patients support beyond DRTB

to include sensitive TB patients / suspects /contacts etc

• Develop strategies to make TB visible ( In partnership with CSOs,

Patients)

• Health system strengthening to address health care system barriers

• OR to evaluate effectiveness of the current incentive interventions

• ACSM strategy focusing on:

– Stigma and Discrimination

– Food security and transport vouchers for all TB patients

– Increase budgetary allocation for TB To render Kenya and its communities free of Leprosy, TB and Lung Disease

Potential actions for addressing the

Barriers in accessing TB services

Thank you

Asante sana