Can Malawi's Poor Afford Free Tuberculosis Services? Patient and Household Costs Associated with a Tuberculosis Diagnosis in Lilongwe
Kemp, Julia R., Mann, Gillian, Simwaka, Bertha Nhlema, Salaniponi, Felix M. L., Squire, Stephen Bertel, Bulletin of the World Health Organization
In 2005, the UN Millennium Summit and the Commission for Africa highlighted the need for increased global development assistance to make progress towards achieving the United Nations Millennium Development Goals (MDGs) by 2015. However, expanding resource allocations to the health sector and scaling up key interventions are unlikely to primarily benefit the poor. (1) This is because current interventions produce inequitable outcomes, favouring the better-off. (2) Furthermore, health MDGs are stated in terms of population averages; this means that even if efforts do not focus on the poor, there may still be progress against the targets. (1)
MDG 6 addresses the need to combat HIV/AIDS, malaria and other priority communicable diseases, including TB, with World Health Assembly 2005 targets to detect 70% of smear-positive TB cases and to successfully treat 85% of such cases. It has become clear that the case detection target is unlikely to be met without accelerated action. (3) However, the link between poverty and TB is profound. Globally the highest burden of TB is found in poor countries, and within countries the prevalence of TB is higher among the poor. (4) Deprivation associated with poverty, including malnutrition and overcrowding, increases the risks of TB infection and disease. (5) Achieving MDG targets for TB therefore requires the identification of effective ways to reach poor populations.
Several studies have assessed the patient and household costs of TB and cost-effectiveness of different approaches to TB treatment in Africa. (6-17) Malawi's National TB Programme has introduced a guardian-based strategy of direct observation of treatment which has reduced costs for patients. (12) Costs to patients and their households of care-seeking from illness onset to diagnosis are less well-documented. (10,17) Most studies of costs to patients and their households present average patient costs. One study from Thailand disaggregates the costs for the poor and presents them relative to annual income. (18) Interestingly, many studies are conducted in settings where TB services are charged for, although in some cases user fees are subsidized.
To achieve international case-detection rates for TB control it is necessary to reduce the economic burden of a TB diagnosis for the poorest. WHO advocates for exemption of TB diagnosis and treatment from cost-recovery strategies so that individuals do not pay for the community benefits of treating TB. (19) However, this paper questions whether removing fees is sufficient to reach the poor. We set out to assess the relative costs of accessing a TB diagnosis for the poor in a setting where public health services are, in theory, universally available: accessible within 6 km and provided free of charge.
The study was conducted in urban Lilongwe, which has the highest burden of TB cases in Malawi. Within the public sector, urban TB diagnostic and treatment services are provided through two hospitals and three urban health centres, where consultations, diagnostic tests and drugs ate provided free of charge. Additional TB services are provided at a not-for-profit mission hospital, where diagnostic tests and treatment are provided free of charge. In accordance with WHO guidelines, TB suspects ate requested to submit three sputum specimens for diagnosis.
The study comprised a cross-sectional, stratified survey of new pulmonary TB patients in the intensive phase of treatment systematically selected from these health facilities within urban Lilongwe between January and June 2001. The study focused on patient and household costs to access diagnosis, since patient costs of different treatment strategies have been reported previously. (12)
Eligible patients were defined as aged 16 years or above and normally resident in Lilongwe. Only patients who were in the intensive phase of treatment were included in the sample because they had only recently started treatment and would have a better recall of the pathway to care. …