Poverty & TB: Global Overview and Kenyan case study

Christy Hanson, PhD, MPHPATH

May 30, 2005CCIH Annual Conference

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

Estimated TB incidence rates 2003

25 to 49

50 to 99

100 to 299

< 10

10 to 24

300 or more

No Estimate

per 100 000 population

TB infected (1.7 billion)

Active TB (8.8 m per year)

HIV at risk (?)

HIV (+) with Active TB (0.7 m)

HIV (+)(40 m)

TB and HIV: Overlapping epidemics

Estimated HIV Prevalence in TB cases, 2002

20 - 49

50 or more

< 5

5 - 19

No estimate

HIV prevalence in TB cases, 15-49 yrs (%)

Global Tuberculosis Control. WHO Report 2003. WHO/HTM/TB/2004.331

Africa: HIV driving the TB epidemicTB notification rates, 1980-2003

0

100

200

300

400

500

80 83 86 89 92 95 98

2002

Rat

e (x

100,

000)

Côte d'Ivoire Kenya Malawi Tanzania Zimbabwe

So

urc

e:

WH

O r

ep

ort

s

TB and HIV in Kenya

0

100

200

300

400

500

600

700

1980 1990 2000 20100.000.020.040.060.080.100.120.140.16

HIV

pre

vale

nce

TB

inci

den

ce

Global Targets for TB control

70% case detection

85% treatment success

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

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%

Evolution of DOTS

Mod

el d

evelo

ped

in

Afr

ica;

Kare

l S

tyb

lo

“DOTS

” br

and

Adop

tion

of D

OTSW

ides

cale

trai

ning

Build

ing

polit

ical c

omm

itmen

t

Resou

rce

mob

iliza

tion

Emer

ging

thre

ats: T

B/HIV

, MDR-T

B

Broad

en o

wners

hip:

priv

ate

sect

or, p

artn

ers

New to

ols: d

iagn

ostic

s, d

rugs

Incr

ease

cas

e de

tect

ion

Adopting DOTS

Expanding DOTS

Adapting DOTS

1995 2005Hea

lth sec

tor r

efor

m

0

50

100

150

200

1990 1993 1995 1996 1997 1998 1999 2000

Nu

mb

er o

f co

un

trie

s

Total number of countries

Number of countries implementing DOTS, 1990 - 2003

Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295

2001 2002 2003

Challenges for the future of TB control

Dual epidemic of TB/HIV

Low case detection rates

Possible cause: not reaching the poor?

Poverty: Inequity between countries

Distribution of PovertyDistribution of population living on less

than $1 a day, 1998 (1.2 billion)

South Asia43%

Sub-Saharan Africa24%

East Asia & Pacific23%

Europe & Central Asia

2%Latin America & Caribbean

7%

Middle East & North Africa

1%

Source: World Bank, WDR 2000

Causes of Poor-Rich Health Status Gap

Communicable Diseases77%

Non-Communicable Diseases – 15%

Injuries8%

1990 Deaths

Sourc

e:

Worl

d B

ank;

Gw

atk

in,

D.;

20

00

* “poor” and “rich” represent poorest countries / richest countries

Disproportionate disease burden among the poor*

010203040506070

% of alldeaths due to

TB

% of DALYslost to TB

Poorest 20%Richest 20%

Sourc

e:

Worl

d B

ank;

Gw

atk

in,

D.;

20

00

* “poor” and “rich” represent poorest countries / richest countries

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

Korea case studyTB And Economic Development

1

10

100

1000

10000

1948 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

Rat

es p

er 1

00,0

00

Unemployment rates

7

350

49

Per capita GNI

TB cases

TB deaths

Korean

War

NT

P

Poverty: Inequity within countries

TB prevalence among poor and non-poor, Philippines

0

1

2

3

4

5

6

Sm+ TB rate per

1000

National Urbannon-poor

Urbanpoor

Source: Tupasi et. al.; IJTLD 4(12): 1126-1132

TB and poverty: correlation in a high-income country

0

10

20

30

40

50

60

70

per

100,

000

East End, London England & Wales

Average Case Rate

TB in the homeless

0100200300400500

San Francisco homeless: TB cases 1992-1996

Annual in

ciden

ce p

er

100

,000

Sou

rce:

Moss

, H

ah

n, Tu

lsky

et

al.;

Am

J R

esp

ir C

rit

Care

Med

20

00

* Notified cases

Poverty: Individual level

TB Epidemiology

ExposureSub-clinical

infection

Infectious TB

Non-infectious TB

Cure, chronic or

Death

Riskfactors

Riskfactors

Riskfactors

Riskfactors

Source: adapted from Urban & Vogel; Am Rev Respir Dis 1981

Income poverty and TBThe poor lack:•Food security

•Income stability •Access to water, sanitation

•Access to health care

Income poverty TB disease

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

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 Women:faster breakdown to TB disease (2x)

Marginalized populations Ethnicity Prisoners

TB case rates by SES indicator: United States 1987-1993

0

10

20

30

40

50

Decreasing SES

TB

cases p

er

10

0,0

00

pers

on

-years

Crowding

Income

Poverty

Unemployment

Education

Source: Cantwell, McKenna, McCray, et al.; Am J Respir Crit Care Med, 1998

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

Reasons for treatment delay: China

Financial45%

Others12%I naccessible

health providers

10%

Not informed

10%

Perception of illness

23%

Source: Ministry of Health, China; 1990 prevalence survey

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%)

Can we meet the MDGs?With current plan 2006-15, not in Africa

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

Africa

high

Africa

low

E Eur

ope

E Med

L Am

erica

SE Asia

W P

acific

Wor

ld

2015

/199

0 va

lues

incidence

prevalence

death

2015 =1990

MDG

Financing public health: caring for the poor?

Financial subsidy from Government health services to poorest & richest 20%

0

5

10

15

20

25

30

%

Africa Asia E Europe Latin Am

Regional averages

Poorest 20% Richest 20%

Source: World Bank, 2001

Expenditures on TB care by level of wealth

0

5

10

15

20

25

30

35

40

Poorest Relativelyrich

Average totalexpenditure oncare seeking forTB illness (US$)Ratio of averageexpenditure towealth score

Sample of patients in Nairobi

Source: Hanson and Kutwa (unpublished)

US

$

Mounting a response

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)

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

Kenyan Case Study

Is the health system responding to poverty dimension of TB?

Trends in Tuberculosis: Kenya

Infectious (smear+) cases of TB

010,00020,00030,00040,00050,00060,00070,00080,00090,000

1995 1997 1999 2002 2003

Estimated sm+ cases (incidence) Sm+ cases detected

Source: WHO reports: 1997, 1998, 1999, 2000,2001, 2002, 2003, 2004, 2005

•46% of population lives in absolute poverty

•>50% of TB patients are HIV+

Evidence of link: TB incidence and poverty

Variance in case notifications by province

0

100

200

300

400

500

0 20 40 60Prevalence of hardcore poverty

TB c

ase

findi

ng

(per

100

,000

)

0

20

40

60

80

100

Evidence of link: TB incidence and poverty

Variance in case notifications by province

0

100

200

300

400

500

0 20 40 60Prevalence of hardcore poverty

TB

ca

se fi

nd

ing

(p

er

10

0,0

00

)

0

20

40

60

80

100

% o

f ch

ildre

n

imm

un

ize

d w

ith

D

PT

3 a

nd

po

lio

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

Survey Tools

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

n=3500

Wealth of TB patients & poverty in their provinces

0

1

2

3

4

5

0 10 20 30 40 50Prevalence of hardcore poverty

Mea

n w

ealth

of

TB

pa

tient

s co

mpl

etin

g tr

eatm

ent

Profile of TB patients treated in public and private sectors

0

10

20

30

40

50

60

% o

f all p

ati

en

ts

Poorest

Q2

Q3

Q4

Wealthiest

Public sector: initiating tx Private sector: initiating txPublic sector: completing tx Private sector: completing tx

3% of patients completing treatment are among the poorest

Change in wealth profile along continuum of diagnosis & treatment

Nyeri

Diagnosis Treatment completion

Most

poor

Least

poor

Where patients go vs. Where the system provides DOTS

0

5

10

15

20

25

dispensary health centre hospital pharmacy

First interaction with health system: poor

public private

Health facilities by type,2001

Health centre12%

Hospital10%

Dispensary61%

Nursing home4%

Health clinic13%

0

20

40

60

80

100

Hospital Health centre Dispensary

Percent of all public facilities that participate in DOTS implementation

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 don’t get referred for diagnosis

• Individual & provider factors behind transitioning

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

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

Voices of the poor: Can anyone hear us?

“The authorities don’t seem to see poor

people. Everything about the poor is

despised, and above all, poverty is despised.”

- Brazil, 1995