1. Poverty & TB: Global Overview and Kenyan case study Christy Hanson, PhD, MPH PATH May 30, 2005 CCIH Annual Conference

2. 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

3. 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

4. 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

5. 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

6. Africa: HIV driving the TB epidemic TB notification rates, 1980-2003 Source: WHO reports

7. TB and HIV in Kenya 0 100 200 300 400 500 600 700 19801990 2000 2010 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16 HIV prevalence TB incidence

8. Global Targets for TB control 70% case detection 85% treatment success

9. 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

10. 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%

11. 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 19952005 Health sector reform

12. 0 50 100 150 200 1990 1993199519961997199819992000 Number of countries Total number of countries Number of countries implementing DOTS, 1990 - 2003 Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295 200120022003

13. Challenges for the future of TB control Dual epidemic of TB/HIV Low case detection rates Possible cause: not reaching the poor?

14. Poverty: Inequity between countries

15. Distribution of Poverty Source: World Bank, WDR 2000

16. 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

17. Disproportionate disease burden among the poor* Source: World Bank; Gwatkin, D.; 2000 * “poor” and “rich” represent poorest countries / richest countries

18. 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

19. Korea case study TB And Economic Development Unemployment rates 7 350 49 Per capita GNI TB cases TB deaths Korean War NTP

20. Poverty: Inequity within countries

21. TB prevalence among poor and non-poor, Philippines Source: Tupasi et. al.; IJTLD 4(12): 1126-1132

22. TB and poverty: correlation in a high-income country

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

24. Poverty: Individual level

25. 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

26. 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

27. 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

28. TB case rates by SES indicator: United States 1987-1993 Source: Cantwell, McKenna, McCray, et al.; Am J Respir Crit Care Med, 1998

29. 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

30. Reasons for treatment delay: China Source: Ministry of Health, China; 1990 prevalence survey

31. 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%)

33. Financing public health: caring for the poor?

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

35. Expenditures on TB care by level of wealth Sample of patients in Nairobi Source: Hanson and Kutwa (unpublished) US$

36. Mounting a response

37. 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)

38. 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

39. Kenyan Case Study Is the health system responding to poverty dimension of TB?

40. Trends in Tuberculosis: Kenya 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+

41. Evidence of link: TB incidence and poverty

43. 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

44. 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

45. Wealth of TB patients & poverty in their provinces

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

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

48. Where patients go vs. Where the system provides DOTS

49. 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

50. 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

51. 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

52. 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