Improving Access to DOTS for the poor in Malawi Julia Kemp, Gillian Mann, Bertha Nhlema, Felix Salaniponi, and Bertie Squire Equi-TB Knowledge Programme & National TB Programme, Malawi

TB control in Malawi Malawi has run a comprehensive DOTS programme since 1984  One of the first countries to pioneer the WHO recommended ‘DOTS’ strategy  National DOTS coverage –integrated throughout the health system, including public & private providers  Free consultation and diagnosis in Public facilities and free drug treatment  Programme indicators: Total cases 26,532 = ~226/100,000 case notification rate (2002) Cure rate 67% (2002) Default 6% and transfer out 3% (2002)  Despite a devastating national HIV epidemic 77% TB cases are HIV+ (1999) TB case fatality 19% (2002)

Do the poor have access to DOTS in Malawi? 1999 NTP embarked on a new initiative to assess whether the DOTS programme reaches the poor  Equi-TB Knowledge Programme Aim to promote access to care, particularly for the poorest Inter-disciplinary research, drawing upon a range of research methods, highlighting the patient & community perspectives on TB control Collaboration between NTP, University of Malawi and Liverpool School of Tropical Medicine

Methodology  A number of different studies focusing on a range of equity issues  Presented Here: Random sample of 179 new pulmonary TB patients at 6 health facilities in Lilongwe Poverty assessment tool developed and tested, based regression analysis of the 1998 Integrated Household Survey Tool applied to assess poverty status of the sample Individual In-depth interviews to assess impact of TB on livelihoods

Characteristics of the Poor Poor people were characterised as:  Living in poorly ventilated and constructed houses  Having few assets  Earning income from casual labour (ganyu), petty trading, or unskilled labour  Being food insecure Non-poor people were characterised as:  Having adequate food  Earning income from medium or large scale businesses, working in the public and private sectors  Living in better houses (e.g. having an iron-sheet roof)

Poverty Status of TB Patients TB patients who make it into the DOTS programme in Lilongwe are poorer than the general population  62% patients within the sample were poor (95% CI: 55-69%)  The general urban population Lilongwe poverty headcount 37.8% (IHS)

The impact of TB is greatest on the poor Poor patients engage in impoverishing coping strategies:  Sold assets (such as pots and pans)  Lost income dependant on the daily input of labour  Took on local loans at a high interest rate  Missed meals or were unable to purchase tap water from the communal tap Non-poor patients were able to mitigate the economic impact of the illness by drawing upon savings or valuable assets. Both poor and non-poor experienced negative consequences of TB BUT the effect was greater on poor TB patients

Evidence that TB cases are ‘missing’ from the poorest areas in Lilongwe? A comparison of Area 18 with Area 56 Area 18 High density, planned settlement Area 56 – Mtsilisa and Ntandile High density, unplanned “squatter” settlement Note: areas are adjacent

How many missing TB cases in the poorest areas? 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 much does it cost for a TB diagnosis in Lilongwe? Costs are both direct (cash expenditure) and indirect (use of non-cash resources)  Cash spent on transport, fees and food for patient and guardian  Men reported more time off work Higher opportunity costs (but reproductive labour difficult to cost)  Women’s labour more likely to be replaced by someone else Labour mostly replaced by girl children – future impact?

Relatively high cost for a TB diagnosis for the poor in Lilongwe (US$) Note: n=179 patients Poverty measured against Integrated Household Survey (IHS) TB diagnosis is free in all public and mission facilities All people live within 6km of a public health facility in urban Lilongwe

Policy responsiveness of NTP to findings on equity in access to TB care New Five Year Development Plan ( )  Testing of interventions to shorten diagnosis pathways for poor communities Store keepers initiative with poor communities in an urban setting Community-based case-finding strategies  Improving overall quality of TB services to reduce diagnostic delays  New communication strategy Using targeted methods and messages for poor populations  Developing better monitoring and evaluation, integrating patient and community perspectives  Understanding delays in accessing care in Rural Malawi