Poverty & TB: Global Overview and Kenyan case study Christy Hanson, PhD, MPH PATH May 30, 2005 CCIH 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 to to to 299 < to or more No Estimate per 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, or more < No estimate HIV prevalence in TB cases, yrs (%) Global Tuberculosis Control. WHO Report WHO/HTM/TB/

Africa: HIV driving the TB epidemic TB notification rates, Source: WHO reports

TB and HIV in Kenya HIV prevalence TB incidence

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 ( ) 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 Model developed in Africa; Karel Styblo “DOTS” brand Adoption of DOTS Widescale training Building political commitment Resource mobilization Emerging threats: TB/HIV, MDR-TB Broaden ownership: private sector, partners New tools: diagnostics, drugs Increase case detection Adopting DOTS Expanding DOTS Adapting DOTS Health sector reform

Number of countries Total number of countries Number of countries implementing DOTS, Global Tuberculosis Control. WHO Report WHO/CDS/TB/

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 Poverty Source: World Bank, WDR 2000

Causes of Poor-Rich Health Status Gap Communicable Diseases 77% Non-Communicable Diseases – 15% Injuries 8% Source: World Bank; Gwatkin, D.; 2000 * “poor” and “rich” represent poorest countries / richest countries

Disproportionate disease burden among the poor* Source: World Bank; Gwatkin, D.; 2000 * “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 study TB And Economic Development Unemployment rates Per capita GNI TB cases TB deaths Korean War NTP

Poverty: Inequity within countries

TB prevalence among poor and non-poor, Philippines Source: Tupasi et. al.; IJTLD 4(12):

TB and poverty: correlation in a high-income country

TB in the homeless Annual incidence per 100,000 Source: Moss, Hahn, Tulsky et al.; Am J Respir Crit Care Med 2000 * Notified cases

Poverty: Individual level

TB Epidemiology Exposure Sub-clinical infection Infectious TB Non-infectious TB Cure, chronic or Death Risk factors Risk factors Risk factors Risk factors Source: adapted from Urban & Vogel; Am Rev Respir Dis 1981

Income poverty and TB The 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 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 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%)

Financing public health: caring for the poor?

Financial subsidy from Government health services to poorest & richest 20% Source: World Bank, 2001

Expenditures on TB care by level of wealth 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 Source: WHO reports: 1997, 1998, 1999, 2000,2001, 2002, 2003, 2004, % of population lives in absolute poverty >50% of TB patients are HIV+

Evidence of link: TB incidence and poverty

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

Profile of TB patients treated in public and private sectors 3% of patients completing treatment are among the poorest

Change in wealth profile along continuum of diagnosis & treatment DiagnosisTreatment completion Most poorLeast poor

Where patients go vs. Where the system provides DOTS

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 1 st 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