TB and Poverty (Dr. Gillian Mann)

TB and Poverty

Gillian Mann

2Poverty and TB

Overview

• What do we mean by poverty and vulnerability?• Higher risk of TB among the poor• Lower access to TB services for the poor• Is TB unusual with regard to poverty?• What can be done?• Where is there more information?

3Poverty and TB

The concepts of poverty and vulnerability

Poverty

• is more than economic poverty (living on ≤US$ 1 per day)

• encompasses lack of opportunities, voice and representation, and vulnerability to shocks

• is a major determinant of vulnerability to disease – especially TB

4Poverty and TB

The relationship between poverty and TB

The poor have

• higher risk of infection

• higher prevalence of disease

• worse outcome of disease

5Poverty and TB

Poor people face higher risk

• TB has been long associated with poverty.

• Seventeen of the twenty-two countries that account for the 80% world’s TB burden are classified as low income.

• Poor and vulnerable people are much more likely to suffer from TB due to socioeconomic factors

• Within countries the prevalence of TB is higher among vulnerable groups such as poor people and the homeless

•Indigenous peoples suffer higher rates of TB than non-indigenous peoples in the same countries, e.g.

– Canada: TB rates are approximately 10times higher among First Nations peoples and up to 90 times higher among the Inuit;

–New Zealand, Pacific Islanders and Maoris have a 22.3 and 10.5 risk rate.

–Kalaallit Nunaat, residents have a risk rate of 45 times that of Danish people

6Poverty and TB

Poor People face higher risk

• Poverty increases the risk of TB infection and disease and TB disease deepens poverty.

• Deprivation associated with poverty, in terms of nutritional deficiencies and weak immune systems, overcrowded housing and lack of access to healthcare, contribute to risk of infection

• Other factors associated with poverty, such as smoking, are high risk factors for TB

7Poverty and TB

Access to Services

8Poverty and TB

Access to services

• Case detection in many countries is low because the poor cannot access TB services

Active TB

Symptoms

recognised

Health care utilisation

Diagnosis

Notification

Infected

Patie

nt d

elay

Health system delay

Patient delay

9Poverty and TB

Area 18 Area 56 Missing

Population 10,677 22,369

Pop density (pop/sq.km) 3,568 3,158

Chronic cough cases 254 182

Smear positive TB cases 41 44

Chronic cough/100,000 2379 814 1565

Smear positive TB/100,000 384 197 187

Actual number of missing chronic cough cases – 350

Actual number of missing smear positive TB cases – 42

Half of all smear positive cases of TB may be missing from the poorest areas

How do we know the poor are not getting access?

10Poverty and TB

Access to services

• The poor face significant costs and delays in accessing TB services; the burden of TB in their communities continues to increase

• The process of accessing care is impoverishing

• Papers: Kemp et al. Can Malawi's poor afford free TB services? Patient and

household costs associated with a TB diagnosis in Lilongwe. Bull World Health Organ 2006; 85(8)

Nhlema-Simwaka et al. Developing a socio-economic measure to monitor access to tuberculosis services in urban Lilongwe, Malawi. IJTLD 2007; 11(1):65-71

11Poverty and TB

Costs of a diagnosis for poor and non poor

All Patients All poor

All non-poor

Direct Costs of Pathway to CareFees and Drugs 7.6 6.6 9.8Transport 3.4 2.6 5.6Food 2 1.8 2.3

Total Direct Costs 13 11 17.7

Opportunity CostsDays Lost 22.1 21.9 23.2Mean income (IHS) $0.71 $0.21 $1.23

Income lost during care seeking 15.8 4.6 28.7

Total Costs $29 $16 $46Total costs as % of monthly income 134% 248% 124%

% income not spent on food 64.8% 42.5% 70.2%

Total costs as % of monthly income after food expenditure 206% 584% 176%

Kemp JR, Mann GH et al Bulletin of the World Health Organisation 2007 85; 580-585.

12Poverty and TB

DOTS since2002

DOTS since1992

13Poverty and TB

People drop out of the diagnostic process: audit in Lilongwe, Feb-Aug 1995

37% of people dropped out of 37% of people dropped out of the diagnostic processthe diagnostic process

499 suspects499 suspects

466 “on-spot”466 “on-spot”

423“early morning”423“early morning”

413“next day spot”413“next day spot”

404 result available404 result available

316 collected result316 collected result

14Poverty and TB

• Inequality: Unequal outcomes; unequal access to health services• Inequity: Inequalities that are unjust

• In 56 low and middle income countries (c. 50% of the world’s population) health inequality is rampant. In relation to the richest 20%, on average the poorest 20% :

•Are twice as likely to have an infant die•Are three times as likely to see their children suffer stunted growth•Have an adolescent fertility rate three times higher

• Health Sector contributes to this:•A poor pregnant woman is more than three times as likely to deliver at

home•A poor child is half as likely to receive full basic immunisation•A poor woman of childbearing age is 40% less likely to practice

contraception

Inequity in the Health Sector

15Poverty and TB

Distribution of Funding

10.1%

13.4%

25.6%

33.1%

17.8%

0.0%

10.0%

20.0%

30.0%

40.0%

Poorest20%

2nd Middle 20% 4th Richest20%

Income Quitiles

Sh

are

of

the

Pu

blic

Su

bsi

dy

Source: NCAER, New Delhi, India (Yazbeck A, Benefit incidence Analysis, Reaching the Poor 2004)

16Poverty and TB

Use of Level of Care: India

0

5

10

15

20

25

30

35

40

Poorest20%

2nd Middle20%

4th Richest20%

Hospital

PHC & Below

Source: Yazbeck A, Benefit incidence Analysis, Reaching the Poor 2004

17Poverty and TB

What can be done?

18Poverty and TB

A trial of transferring up-front, out-of-pocket expenditure from patients to TB dispensaries (funded through New Cooperative Medical Scheme in Hunan Province, China)

19Poverty and TB 19

Result: outpatient costs significantly reduced

20Poverty and TB

Hurdles faced by an average rural resident accessing TB treatment in Malawi

Source:Gillian MannPhD ThesisUniversity of Liverpool2008

NB: no user fees in public health facilities

21Poverty and TB

Potential effect of front-loading of sputum collection for smear microscopy

22Poverty and TB

Potential effect of frontloading with same-day issue of results

23Poverty and TB

What information is there: Guidelines for NTPs

1. Identification of the poor and vulnerable groups in the country/region served by the national TB control programme

2. Identification of the barriers to accessing TB services faced by the poor and vulnerable groups in the country/region

3. Identification of potential actions to overcome the barriers to access

4. Identification of situations and population groups requiring special consideration

5. Harnessing resources for pro-poor TB services

6. Assessment of the pro-poor performance of the national TB control programme and the impact of pro-poor measures

http://www.stoptb.org/tbandpoverty/steps.aspWHO/HTM/TB/2005.352May 2005

24Poverty and TB

Summary

• Poor people are more likely to have TB and less likely to receive care

• We need to be sure that TB programmes are finding ways to reach the poor and to facilitate access to care

• We need to make sure new tools are accessible to poor people

25Poverty and TB

Thank You

26Poverty and TB

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11

0 1 2 3 4 5 Kilometers

Percentage of Householdswith Private Piped Water

Private Piped Water

Source: 1998 National Census

0 - 20

21 - 40

41 - 60

61 - 80

81 - 100

Poverty indicators/area– Lilongwe (Malawi)

44

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3142

11

0 1 2 3 4 5 Kilometers

Population %with Secondary Education

Pop < 100

Secondary Education

Source: 1998 National Census

0 - 6

7 - 23

25 - 30

31 - 47

27Poverty and TB

44

25

45

49 43

46

47

3

35

36

56

23

38

50

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24

7

1

29

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5

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433

41

16

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32 1315

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3142

11

0 1 2 3 4 5 Kilometers

Percentage of Householdswith Private Piped Water

Private Piped Water

Source: 1998 National Census

0 - 20

21 - 40

41 - 60

61 - 80

81 - 100

Poverty indicators/area – Lilongwe (Malawi)

44

25

45

49 43

46

47

3

35

36

56

23

38

50

57

24

7

1

29

29

10

8

22

18

34

21

30

6

5

12

37

39

14

433

41

16

28

20

17

32 1315

48

40

3142

11

0 1 2 3 4 5 Kilometers

Population %with Secondary Education

Pop < 100

Secondary Education

Source: 1998 National Census

0 - 6

7 - 23

25 - 30

31 - 47

Mitsiriza

Ngwenya

28Poverty and TB

44

25

45

49 43

46

47

3

35

36

56

23

38

50

57

24

7

1

29

29

10

8

22

18

34

21

30

6

5

12

37

39

14

433

41

16

28

20

17

32 1315

48

40

3142

11

0 1 2 3 4 5 Kilometers

Percentage of Householdswith Private Piped Water

Private Piped Water

Source: 1998 National Census

0 - 20

21 - 40

41 - 60

61 - 80

81 - 100

Poverty indicators/area – Lilongwe (Malawi)

44

25

45

49 43

46

47

3

35

36

56

23

38

50

57

24

7

1

29

29

10

8

22

18

34

21

30

6

5

12

37

39

14

433

41

16

28

20

17

32 1315

48

40

3142

11

0 1 2 3 4 5 Kilometers

Population %with Secondary Education

Pop < 100

Secondary Education

Source: 1998 National Census

0 - 6

7 - 23

25 - 30

31 - 47

Mitsiriza

Ngwenya

29Poverty and TB

An example of a quantitative proxy measure

B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71

30Poverty and TB

An example of a qualitative matrix

B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71

31Poverty and TB

Household Poverty indicators

Variable Coefficient t-statistic Household cooks over collected firewood -.0.174 3.58* Household size -0.283 19.12* Household size squared 0.015 11.93* Education level of household head 0.078 6.65* No of salaried household members 0.098 4.11* Household owns a bicycle 0.153 6.93* Household owns a car or motor cycle 0.693 8.16* Household owns a fridge 0.591 5.69* Purchased sugar in last 2 weeks 0.152 7.06* Total acreage cultivated 0.029 6.70* Household grows tobacco 0.105 4.03* Household owns a bed 0.263 11.85* No of cattle owned 0.013 3.1* Household grows hybrid maize 0.076 3.28* Nkhata Bay 0.123 -0.92 Dedza 0.030 -0.24 Mchinji -0.052 -0.31