TB and Poverty Gillian Mann

2 Poverty 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?

3 Poverty 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

4 Poverty and TB The relationship between poverty and TB The poor have higher risk of infection higher prevalence of disease worse outcome of disease

5 Poverty 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

6 Poverty 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

7 Poverty and TB Access to Services

8 Poverty 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 NotificationInfected Patient delay Health system delay Patient delay

9 Poverty and TB Area 18Area 56Missing Population10,67722,369 Pop density (pop/sq.km)3,5683,158 Chronic cough cases Smear positive TB cases4144 Chronic cough/100, Smear positive TB/100, 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?

10 Poverty 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

11 Poverty and TB Costs of a diagnosis for poor and non poor Kemp JR, Mann GH et al Bulletin of the World Health Organisation ;

12 Poverty and TB DOTS since 2002 DOTS since 1992

13 Poverty and TB People drop out of the diagnostic process: audit in Lilongwe, Feb-Aug 1995  37% of people dropped out of the diagnostic process 499 suspects 466 “on-spot” 423“early morning” 413“next day spot” 404 result available 316 collected result

14 Poverty 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

15 Poverty and TB Distribution of Funding Source: NCAER, New Delhi, India (Yazbeck A, Benefit incidence Analysis, Reaching the Poor 2004)

16 Poverty and TB Use of Level of Care: India Source: Yazbeck A, Benefit incidence Analysis, Reaching the Poor 2004

17 Poverty and TB What can be done?

18 Poverty 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)

19 Poverty and TB 19 Result: outpatient costs significantly reduced

20 Poverty and TB Hurdles faced by an average rural resident accessing TB treatment in Malawi Source: Gillian Mann PhD Thesis University of Liverpool 2008 NB: no user fees in public health facilities

21 Poverty and TB Potential effect of front-loading of sputum collection for smear microscopy

22 Poverty and TB Potential effect of frontloading with same-day issue of results

23 Poverty 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 WHO/HTM/TB/ May 2005

24 Poverty 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

25 Poverty and TB Thank You

26 Poverty and TB Poverty indicators/area– Lilongwe (Malawi)

27 Poverty and TB Poverty indicators/area – Lilongwe (Malawi) Mitsiriza Ngwenya

28 Poverty and TB Poverty indicators/area – Lilongwe (Malawi) Mitsiriza Ngwenya

29 Poverty and TB An example of a quantitative proxy measure B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71

30 Poverty and TB An example of a qualitative matrix B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71

31 Poverty and TB Household Poverty indicators