Communication strategy

							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
Both poor and non-poor experienced negative consequences
of TB BUT the effect was greater on poor TB patients

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.
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 18     Area 56     Missing

Population                                 10,677      22,369
Pop density (pop/sq.km)                     3,568       3,158
Chronic cough cases                           254         182
Smear positive TB cases                        41          44
Chronic cough/100,000                       2379          814       1565
Smear positive TB/100,000                     384         197        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
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$)
                                                  All                   All non-    Note:
                                                Patients    All poor     poor
                                                                                    n=179 patients
Direct Costs of Pathway to Care
Fees and Drugs                                        7.6         6.6         9.8
Transport                                             3.4         2.6         5.6   Poverty measured
Food                                                  2.0         1.8         2.3
                                                                                    against Integrated
Total Direct Costs                                   13.0        11.0        17.7   Household Survey
Opportunity Costs                                                                   (IHS)
Days Lost (days)                                     22.1        21.9        23.2
Mean income (IHS)                                   $0.71       $0.21       $1.23
                                                                                    TB diagnosis is free in
Income lost during care seeking                       $16          $5         $29
                                                                                    all public and mission
Total Costs                                           $29         $16         $46   facilities
Total costs as % of monthly income                  134%        248%        124%

% income not spent on food                           65%         42%         70%    All people live within
Total costs as % of monthly income after food                                       6km of a public health
expenditure                                         206%        584%        176%    facility in urban
                                                                                    Lilongwe
Policy responsiveness of NTP to findings on equity
in access to TB care

New Five Year Development Plan (2002-2006)
   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