TB and Poverty

Gillian Mann

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?

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
Poverty and TB

The relationship between poverty and TB

The poor have higher risk of infection higher prevalence of disease worse outcome of disease

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% worlds 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
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

Poverty and TB

Access to Services

Poverty and TB

Access to services
Case detection in many countries is low because the poor cannot access TB services

nt ie t Pa

ay el d

Symptoms recognised

Patient delay

Health care utilisation

th al He em st sy la de y

Active TB

Diagnosis

Poverty and TB

Infected

Notification

How do we know the poor are not getting access?

Area 18 Population Pop density (pop/sq.km) Chronic cough cases Smear positive TB cases Chronic cough/100,000 Smear positive TB/100,000 10,677 3,568 254 41 2379 384

Area 56 22,369 3,158 182 44 814 197

Missing

1565 187

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
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

Poverty and TB

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Costs of a diagnosis for poor and non poor

All Patients All poor Direct Costs of Pathway to Care Fees and Drugs Transport Food Total Direct Costs Opportunity Costs Days Lost Mean income (IHS) Income lost during care seeking Total Costs Total costs as % of monthly income % income not spent on food Total costs as % of monthly income after food expenditure
Poverty and TB

All nonpoor 9.8 5.6 2.3 17.7 23.2 $1.23 28.7 $46 124% 70.2% 176%

7.6 3.4 2 13 22.1 $0.71 15.8 $29 134% 64.8% 206%

6.6 2.6 1.8 11 21.9 $0.21 4.6 $16 248% 42.5% 584%

Kemp JR, Mann GH et al Bulletin of the World Health Organisation 2007 85; 580585.
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DOTS since 2002

Poverty and TB

DOTS since 1992

12

People drop out of the diagnostic process: audit in Lilongwe, Feb-Aug 1995

499 suspects 466 on-spot 423early morning 413next day spot

37% of people dropped out of the diagnostic process

404 result available 316 collected result

13

Poverty and TB

Inequity in the Health Sector

Inequality: Unequal outcomes; unequal access to health services Inequity: Inequalities that are unjust In 56 low and middle income countries (c. 50% of the worlds 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
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Distribution of Funding
40.0% Share of the Public Subsidy
33.1%

30.0%

25.6%

20.0%
13.4% 17.8% 10.1%

10.0%

0.0% Poorest 20% 2nd Middle 20% Income Quitiles

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

4th

Richest 20%

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Use of Level of Care: India

40 35 30 25 20 15 10 5 0 Poorest 20% 2nd Middle 20% 4th Richest 20% Hospital PHC & Below

Source: Yazbeck A, Benefit incidence Analysis, Reaching the Poor 2004

Poverty and TB

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What can be done?

Poverty and TB

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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)

Poverty and TB

18

Result: outpatient costs significantly reduced

Poverty and TB

19

19

Hurdles faced by an average rural resident accessing TB treatment in Malawi

NB: no user fees in public health facilities

Source: Gillian Mann PhD Thesis University of Liverpool 2008

Poverty and TB

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Potential effect of front-loading of sputum collection for smear microscopy

Poverty and TB

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Potential effect of frontloading with same-day issue of results

Poverty and TB

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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 http://www.stoptb.org/tbandpoverty/steps.asp
Poverty and TB

WHO/HTM/TB/2005.352 May 2005

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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

Poverty and TB

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Thank You

Poverty and TB

25

Poverty indicators/area Lilongwe (Malawi)

Secondary Education
Population % with Secondary Education
0-6 7 - 23 25 - 30 31 - 47

Private Piped Water

Percentage of Households with Private Piped Water
0 - 20 21 - 40 41 - 60 61 - 80 81 - 100

25

Pop < 100 Source: 1998 National Census

25

Source: 1998 National Census

29 50 28 43

39
50 28

29

39

49

30

49

30

43

18 56 48 14 47 15 6 5 9 46 3 37 57 1 8 4 32 33 2 7 20

10
56 48

18 20 14

10 12 34 17 7 21 8 22 23 41 44

42 31 11 13

12 34 17

41 44
47 15 6

42 31 11 13 33

40 16

40 16 32

35
46

5 9 3

35

21

22 23 45 36 24

37 57

45

36 24

5 Kilometers

38

5 Kilometers

38

Poverty and TB

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Poverty indicators/area Lilongwe (Malawi)

Secondary Education
Population % with Secondary Education
0-6 7 - 23 25 - 30 31 - 47

Private Piped Water

Percentage of Households with Private Piped Water
0 - 20 21 - 40 41 - 60 61 - 80 81 - 100

25

Pop < 100 Source: 1998 National Census

25

Source: 1998 National Census

29 50 28 43

39
50 28

29

39

49

30

49

30

43

Mitsiriza

18 48 14 47 15 6 5 9 4 32 33 2 7 20

56

10
56 48

18 20 14

10 12 34 17 7 21 8 22 23 41 44

42 31 11 13

12 34 17

41 44
47 15 6

42 31 11 13 33

40 16

40 16 32

35
46

5 9 3

46 3 37 57 1 8

35

21

22 23 45 36 24

37 57

Ngwenya
38

45

36 24

5 Kilometers

5 Kilometers

38

Poverty and TB

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Poverty indicators/area Lilongwe (Malawi)

Secondary Education
Population % with Secondary Education
0-6 7 - 23 25 - 30 31 - 47

Private Piped Water

Percentage of Households with Private Piped Water
0 - 20 21 - 40 41 - 60 61 - 80 81 - 100

25

Pop < 100 Source: 1998 National Census

25

Source: 1998 National Census

29 50 28 43

39
50 28

29

39

49

30

49

30

43

Mitsiriza

18 48 14 47 15 6 5 9 4 32 33 2 7 20

56

10
56 48

18 20 14

10 12 34 17 7 21 8 22 23 41 44

42 31 11 13

12 34 17

41 44
47 15 6

42 31 11 13 33

40 16

40 16 32

35
46

5 9 3

46 3 37 57 1 8

35

21

22 23 45 36 24

37 57

Ngwenya
38

45

36 24

5 Kilometers

5 Kilometers

38

Poverty and TB

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An example of a quantitative proxy measure

B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71

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An example of a qualitative matrix

B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71

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Household Poverty indicators

Variable Household cooks over collected firewood Household size Household size squared Education level of household head No of salaried household members Household owns a bicycle Household owns a car or motor cycle Household owns a fridge Purchased sugar in last 2 weeks Total acreage cultivated Household grows tobacco Household owns a bed No of cattle owned Household grows hybrid maize Nkhata Bay Dedza Mchinji Coefficient -.0.174 -0.283 0.015 0.078 0.098 0.153 0.693 0.591 0.152 0.029 0.105 0.263 0.013 0.076 0.123 0.030 -0.052 t-statistic 3.58* 19.12* 11.93* 6.65* 4.11* 6.93* 8.16* 5.69* 7.06* 6.70* 4.03* 11.85* 3.1* 3.28* -0.92 -0.24 -0.31

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