1. Health care utilization patterns and economic consequences of TB Dr. K. Zaman ICDDR,B National TB Conference 2007, NATAB

2. Background 8.8 million new cases of TB, 1.6 million deaths globally in a year TB causes 1.6 million DALYs loss annually among low- and middle-income countries Poor patients seek care – frequently from non- licensed providers Delay in diagnosis & start treatment Put economic burden on families

3. Distribution of tuberculosis in the world Dye C. Lancet 2006;367:938-40 Ranks 5 th globally Ranks 5 th globally Incidence all Incidence all cases 227/100K cases 227/100K /Yr /Yr Incidence SS+ve cases 102/100K/Yr Incidence SS+ve cases 102/100K/Yr 300,000 new cases in a year 300,000 new cases in a year 70,000 deaths/year 70,000 deaths/year

4. Objectives To describe health care utilization patterns of TB suspects and TB cases To assess the economic consequences of TB at family level

5. Population prevalence of smear positive TB cases by age and gender- Matlab *** p<0.0001 Zaman et al, 2006

6. From cough to cure pathway Care seeking Non TB / Irregular treatment TB suspects Cough > 21 Days TB specific treatment Diagnosis as TB Expenditure Impact Coping with TB Beginning of TB symptoms

7. TB Surveillance in Rural Matlab Routine surveillance in Routine surveillance in the intervention area the intervention area Referral of all suspected Referral of all suspected cases to Matlab THC cases to Matlab THC Specific data collection Specific data collection from all areas from all areas

8. General Characteristics of TB cases in rural Matlab ItemsIntervention N = 81 (%) Non- Intervention N = 82 (%) All N =163 (%) Family Size5.275.395.33 No Schooling38 ( 46.9)37 (45.1)75(47.3) Monthly income (Taka)401939393979

9. Care sought: First consultation by TB Cases Type of providerIntervention N = 81 (%) Non- intervention N=82 (%) All N =163 (%) Non-graduate allopath17 (20.9)24 (29.2)41 (25.1) Pharmacy21 (25.9)20(24.3)41 (25.1) Homeopath01 (1.2)1 (0.6) NGO4 (4.9)04 (2.4) THC6 (7.4)3 (3.6)9 (5.5) ICDDR,B19 (23.4)019 (11.6) Graduate Allopath (GP)11 (13.6)27 (32.9)38 (23.3) Others3 (3.7)7 (8.5)10 (6.1)

10. Knowledge about TB and TB services ItemsIntervention N = 81 (%) Non- intervention N=82 (%) All N =163 (%) Know signs / symptoms of TB 65 (80.2)64 (78.0)129 (79.1) Know free TB treatment available 73 (90.1)71 (86.5)144 (88.3) TB case in the Family33 (40.7)24 (29.2)57(34.9)

11. Survey of TB suspects in Urban areas Adults screened for cough > 3 weeks 60,382 TB suspects 1,138 (1.9%) TB suspects interviewed 1,046 (91.9%)

12. Sought care 648 (62%) DOTS (Public + NGO) 106 (16.4%) NON - DOTS (Private Sector) 542 (83.6%) Care seeking of suspected TB cases

13. Measures taken by different providers †Measures taken at DOTS centre not shown Chronic coughers1046 Care sought 648 (62%) Measures taken by provider Percentage of provider Graduate PP (n=111) Non- graduate PP (n=283) Pharmacy & others (n =148) Investigations2.70.42.0 Advises2.70.7 Prescribed drugs 93.797.995.3 Refer to DOTS0.00.40.0 Refer to another providers 0.90.40.0 Others0.00.42.0

14. General Characteristics of TB cases in urban areas Subjects (N = 40) AverageComments Family Size4.8- Monthly income in past month Patient (Taka) 257723% had no income Monthly income in past month Household (Taka) 41015% had no income No. of visit to providers before specific treatment 2.6Range 1- 5 visits

15. Expenditure before TB treatment ExpenditureNumber of patients Range (Taka) Mean (Taka) Provider fee205 – 2760214 Diagnostic cost820 – 4192823 Medicine cost1630 – 3500767 Transport cost2310 – 1250128 Other cost1810 – 1400220 Total expenditure37 10 - 9270811

16. Impact on work ItemsN = 40Comments Preceding month of Diagnosis 67%Work loss 16 days (2-30days) Previous 3 months of diagnosis 50%Stop/Reduce/change jobs Previous 3 months of diagnosis 20% Interfered work of other members Other members started new job Members stopped schooling (10%)

17. Impact on Household ItemsN = 40Comments Changes regular expenditures 90 %Adjusted in the families Health expenditure56 %increased Food expenditure due to illness 53 %increased Transport related expenditure 36 %increased

18. Coping Strategies ItemsN = 40Comments Adopted coping strategies 48 % of Households Taking loan30 % Accepting Donations20 %Relatives and friends Savings17.5 %Stop or use previous Sale of properties10 %

19. Conclusions Many TB suspects sought care from non-DOTS Most of them knew the signs and symptoms of TB Significant expenditure before diagnosis of TB Many adopted coping strategies Poses high economic burden to the families

20. Government of Bangladesh (NTP) Matlab THC BRAC WHO All partners of NTP ICDDR,B Collaboration