GLOBAL TB PROGRAMME Knut Lönnroth Global TB Programme, WHO Monitoring social protection Sickness insurance Food package Disability grants Other welfare.

GLOBAL TB PROGRAMME

Knut Lönnroth

Global TB Programme, WHO

Monitoring social protection

Sickness insurance

Food package

Disability grants

Other welfare grants

Travel vouchers

Mechanisms Outcomes

Case detection

% with catastrophic cost

Treatment outcome

Access to social protection interventions

for TB patients

Housing support

Other cash transfer

Situation assessment Monitoring of coverage and outcomes

Job security

GLOBAL TB PROGRAMME

Proposed key indicatorsIndicator Definition Sources Global target

Percentage of people with TB with some form of social or economic support benefits

Numerator: Number of people receiving care for TB and receiving social protection benefits Denominator: Total number of people receiving care for TB

NTP register cross-checked with other registers

Country level only

Percentage of people with TB who face catastrophic costs

Numerator: Number of people receiving care for TB and experiencing catastrophic costs (direct medical, non-medical and income loss combined) due to TB illness and TB care Denominator: Total number of people receiving care for TB

Periodic surveys of patients receiving care for TB

0%

Lönnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention. PLoS Med 2014; 11(9): e1001693

GLOBAL TB PROGRAMME

TARGETS• 35% reduction in

TB deaths

• 20% reduction TB incidence rate (<85/100 000)

• No affected families with catastrophic costs due to TB

TARGETS• 75% reduction in

TB deaths

• 50% reduction TB incidence rate (<55/100 000)

• No affected families with catastrophic costs due to TB

TARGETS• 90% reduction in

TB deaths

• 80% reduction TB incidence rate (<20/100 000)

• No affected families with catastrophic costs due to TB

GOAL

• 95% reduction in TB deaths

• 90% reduction TB incidence rate (<10/100 000)

• No affected families with catastrophic costs due to TB

20352020 20302025

Milestones in WHO's post-2015 global TB strategy

GLOBAL TB PROGRAMME

Integrated, patient-centered TB Care and

Prevention (free of charge)

Early diagnosis of TB including universal drug-susceptibility testing ; systematic screening of contacts and high-risk groups

Treatment of all forms of TB including drug -resistant TB with patient support

Collaborative TB/HIV activities and management of co-morbidities

Preventive treatment for high-risk groups and vaccination of children

Bold policies and supportive systemsGovernment stewardship , commitment, and adequate resources for TB care and control with monitoring and evaluation

Engagement of communities , civil society organizations, and all public and private care providers

Universal health coverage policy; and regulatory framework for case notification, vital registration, drug quality and rational use, and infection control

Social protection, poverty alleviation, and actions on other determinants of TB

Intensified Research and Innovation

Discovery, development and rapid uptake of new tools, interventions and strategies

Operational research to optimize implementation and impact, and promote innovations

Post-2015 Global TB Strategy

GLOBAL TB PROGRAMME

Mean cost as percentage of annual individual income

Higher cost among:• People with MDR-TB• People from low socioeconomic groups

Source: Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients in low- and middle-income countries – a systematic review. ERJ 2014

GLOBAL TB PROGRAMME

Composition of TB related costs, on average

Medical expenditure

8%

Other expenditure

10%

Lost income33%Lost income

26%

Other expenditure8%

Medical expenditure

17%

Medical expenditure Other expenditure Lost income

UHC + social pro-

tection

During treatment50% of total costs

Before treatment50% of total costs

UHC

GLOBAL TB PROGRAMME

Coping mechanisms

% taking lone

% selling household

items

% using own

savings

% transfers from

relatives

Myanmar, Urban, 2004, 55.3%      India, Rural, 2000, 71%      Thailand, Nationwide, 1996/97, Income below poverty line 12% 16% 22% 23%Thailand, Nationwide, 1996/97, Income below average 9% 7% 21% 21%Thailand, Nationwide, 1996/97, Income above average 8% 8% 14% 17%India, Urban & Rural, , government 76%India, Urban & Rural, , NGO 58%India, Urban & Rural, , private urban 68%China, Rural, 2002-2005, 8% 45%   66%Ghana, Urban & Rural, NA, 47% 37%    Viet Nam, Urban & Rural, NA, 17% 5%    

Dominican Republic, Urban & Rural, NA, 45% 19%    Tajikistan, Urban & Rural, 2006/07, 30% 49% 30%  

GLOBAL TB PROGRAMME

DefinitionsWHO definition of UHC:

a) universal access to needed health services;

b) without financial hardship in paying for them (i.e. concerned with out-of-pocket medical expenses only)

WHO definition of "catastrophic health expenditure”:

Direct health care expenditures corresponding to >40% of annual discretionary income" (income after basic needs, such as food and housing). (i.e. indirect costs of care and income loss are not included).

ILO definition of social protection:

c) Access to Essential Services (water and sanitation, health, education, etc);

d) Essential Social Transfers (cash and in kind, paid to the poor and vulnerable) To enhance food security and nutrition, To provide a minimum income security and access to services Income replacement and social support in the event of illness

GLOBAL TB PROGRAMME

The three dimensions of UHC

GLOBAL TB PROGRAMME

UHC with added protection for non-medical costs of illness & care

Direct non-medical costs and income loss

Transfers: -Cash transfers -Travel vouchers -Food assistance -Etc.

People centred delivery: -Minimized hospitalization -Decentralization -Reduced waiting

Uni

vers

al h

ealth

cov

erag

e

TB diagnosis and treatment quality TB service coverage

Financial risk protection for TB-affected households

Soci

al p

rote

ction

Lönnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention. PLoS Med 2014; 11(9): e1001693

GLOBAL TB PROGRAMME

Knut Lönnroth

Global TB Programme, WHO

Sickness insurance

Food package

Disability grants

Other welfare grants

Travel vouchers

Mechanisms Outcomes

Case detection

% with catastrophic cost

Treatment outcome

Access to social protection

interventions

Housing support

Other cash transfer

Situation assessment Monitoring of coverage and outcomes

Job security

Monitoring framework

GLOBAL TB PROGRAMME

Proposed key indicatorsIndicator Definition Sources Global target

Percentage of people with TB with some form of social or economic support benefits

Numerator: Number of people receiving care for TB and receiving social protection benefits Denominator: Total number of people receiving care for TB

NTP register cross-checked with other registers

Country level only

Percentage of people with TB who face catastrophic costs

Numerator: Number of people receiving care for TB and experiencing catastrophic costs (direct medical, non-medical and income loss combined) due to TB illness and TB care Denominator: Total number of people receiving care for TB

Periodic surveys of patients receiving care for TB

0%

Lönnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention. PLoS Med 11(9): e1001693

GLOBAL TB PROGRAMME

Definition of catastrophic cost - options:

1. Total cost as percentage of annual household income (over a defined level) Requires collection of direct and indirect cost data plus income data Possible cut-off:

>20% (which is associated with poor treatment outcomes, Wingfield et al, 2014)? >10% (judged to have important financial implications, at least for poor families)?

2. Any occurrence of important "Dissaving" Requires much simpler questions about potentially irreversible coping

mechanisms: Taking out a loan Selling property/livestock/household items

Associated with total cost and total cost as percentage of income (Madan et al, 2014)

GLOBAL TB PROGRAMME

Data collection approaches

1. Routine surveillance data from TB register (monitoring access to social protection only)

2. TB patient survey (diagnosed cases)

3. TB prevalence surveys

4. Health expenditure subaccount for TB (too small sample probably)

GLOBAL TB PROGRAMME

The patient cost tool

• Generic survey instrument with tools for country adaptation (KNCV, WHO and JATA, 2010)

• Built on rich previous research • Study population: people diagnosed with TB• Recently adapted to people with MDR-TB

• Domains– Health seeking (provider utilization, delay)– Direct cost for diagnosis, treatment , transport, etc– Indirect costs (income loss)– Social consequences (divorce, interrupted education, etc)– Coping mechanisms (loans, selling goods, etc)– Patient characteristics (age, sex, socioeconomic status, etc)– Access to social protection

GLOBAL TB PROGRAMME

Where and how often?

Sample: • National random samples?• Sentinel sites?

Frequency:• Every 5 years?• More often?

Global monitoring:• Baseline in 2015/16• All countries or panel of countries?• Every year? Every 5 years?

GLOBAL TB PROGRAMME

Next steps• Further methodological development

Planned meeting on social protection interventions and monitoring, tentatively March 2015

Including meeting task force on monitoring social protections

• Demonstration studies in selected countries in all regions Select 2-3 countries in WPR?

• Continued support to countries so that baseline can be established for 2015-2016 All WPR priority countries?