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					The contribution of research to improving access
to health care for TB patients
Dr S B Squire, Reader in Clinical Tropical Medicine, LSTM, and Secretary
of the TB & Poverty Subgroup
The contribution of research - Overview

1. Improved understanding of the concept of poverty

2. Improved understanding of the relationship between poverty
   and TB

3. Documenting the barriers (hurdles) faced by poor patients
   accessing TB Services

4. Identifying, piloting, and assessing the impact of ways of
   overcoming access hurdles

5. Ensuring that the poor are not forgotten in New Tools
   Research



STOP TB Symposium 2009                                          2
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


STOP TB Symposium 2009                      3
Poverty indicators/area– Lilongwe (Malawi)

                                                                                                Secondary Education                                                                                                                 Private Piped Water
                                                                                                       Population %                                                                                                                 Percentage of Households
                                                                                                 with Secondary Education                                                                                                            with P rivate P iped W ater
                                                                                                                    0-6                                                                                                                                0 - 20

                                                                                                                    7 - 23                                                                                                                             21 - 40

                                                                                                                    25 - 30                                                                                                                            41 - 60

                                                                                                                    31 - 47                                                                                                                            61 - 80

                                                                                                                    Po p < 1 00                                                                                                                        81 - 100
                               25                                                                So urce: 199 8 N ation al Cen sus
                                                                                                                                                                   25                                                               So urce: 199 8 N ation al Cen sus




                                                                        29
                                                                                    39                                                                                                                      29
                                                                                                                                                                                                                        39
                                   50
                                                      28                                                                                                               50
                                                                                                                                                                                          28


                         49                                               43
                                                  30                                                                                                         49                                               43
                                                                                                                                                                                      30


                                            18                                                                                                                                  18
                                                           20            10                                                                                                                                  10
           56             48                                                                                                                                  48                               20
                                                                42                                                                             56
                                                  14        31 11                                                                                                                                   42
                                                                               12         41                                                                                          14        31 11              12         41
                    47                 15             40 16                                                                                             47
                                                                                                               44                                                          15             40 16
                                                                    13         34                                                                                                                                  34                             44
                                    6            32                                                                                                                                  32                 13
                                                                                                                                                                        6
                                   5                       33                 17                                                                                       5                                          17
                                        4                                                  35                                                                                                  33
                         9                                                                                                                                                  4                                                  35
                                                  2                                                                                                          9
                                                                    7                                                                                                                 2
          46                                                                                                                                                                                            7
                                                                                                                                              46
                               3                                              21                                                                                                                                  21
                                                                                                                                                                   3
                                                                8                                                                                                                                   8
                                        37            1                                                                                                                                   1
                                                                                                                                                                            37
     57                                                             22                                                                   57                                                             22

                                                                                     23                                                                                                                                  23
                45                                36                                                                                                45                                36

                                                                         24                                                                                                                                  24



                                                                                    38                                                                                                                                  38
 0    1    2    3        4     5 Kilometers                                                                                          0    1    2    3        4     5 Kilometers



     STOP TB Symposium 2009                                                                                                                                                                                                                                     4
Poverty indicators/area – Lilongwe (Malawi)

                                                                                                Secondary Education                                                                                                                 Private Piped Water
                                                                                                       Population %                                                                                                                 Percentage of Households
                                                                                                 with Secondary Education                                                                                                            with P rivate P iped W ater
                                                                                                                    0-6                                                                                                                                0 - 20

                                                                                                                    7 - 23                                                                                                                             21 - 40

                                                                                                                    25 - 30                                                                                                                            41 - 60

                                                                                                                    31 - 47                                                                                                                            61 - 80

                                                                                                                    Po p < 1 00                                                                                                                        81 - 100
                               25                                                                So urce: 199 8 N ation al Cen sus
                                                                                                                                                                   25                                                               So urce: 199 8 N ation al Cen sus




                                                                        29
                                                                                    39                                                                                                                      29
                                                                                                                                                                                                                        39
                                   50
                                                      28                                                                                                               50
                                                                                                                                                                                          28


                         49                                               43
                                                  30                                                                                                         49                                               43
                                                                                                                                                                                      30


                                            18                                                                                                                                  18
                                                                         10                                                                                                                                  10
Mitsiriza
        56                48                               20
                                                                42                                                                             56             48                               20
                                                                                                                                                                                                    42
                                                  14        31 11              12         41                                                                                          14        31 11              12         41
                    47                 15             40 16                                                                                             47
                                                                                                               44                                                          15             40 16
                                                                    13         34                                                                                                                                  34                             44
                                    6            32                                                                                                                                  32                 13
                                                                                                                                                                        6
                                   5                       33                 17                                                                                       5                                          17
                                        4                                                  35                                                                                                  33
                         9                                                                                                                                                  4                                                  35
                                                  2                                                                                                          9
                                                                    7                                                                                                                 2
           46                                                                                                                                                                                           7
                                                                                                                                              46
                               3                                              21                                                                                                                                  21
                                                                                                                                                                   3
                                                                8                                                                                                                                   8
                                        37            1                                                                                                                                   1
                                                                                                                                                                            37
      57                                                            22                                                                   57                                                             22

                                                                                     23                                                                                                                                  23
                45                                36                                                                                                45                                36

                                                                         24    Ngwenya                                                                                                                       24



                                                                                    38                                                                                                                                  38
  0    1    2   3        4     5 Kilometers                                                                                          0    1    2    3        4     5 Kilometers



      STOP TB Symposium 2009                                                                                                                                                                                                                                    5
Poverty indicators/area – Lilongwe (Malawi)

                                                                                                Secondary Education                                                                                                                 Private Piped Water
                                                                                                       Population %                                                                                                                 Percentage of Households
                                                                                                 with Secondary Education                                                                                                            with P rivate P iped W ater
                                                                                                                    0-6                                                                                                                                0 - 20

                                                                                                                    7 - 23                                                                                                                             21 - 40

                                                                                                                    25 - 30                                                                                                                            41 - 60

                                                                                                                    31 - 47                                                                                                                            61 - 80

                                                                                                                    Po p < 1 00                                                                                                                        81 - 100
                               25                                                                So urce: 199 8 N ation al Cen sus
                                                                                                                                                                   25                                                               So urce: 199 8 N ation al Cen sus




                                                                        29
                                                                                    39                                                                                                                      29
                                                                                                                                                                                                                        39
                                   50
                                                      28                                                                                                               50
                                                                                                                                                                                          28


                         49                                               43
                                                  30                                                                                                         49                                               43
                                                                                                                                                                                      30


                                            18                                                                                                                                  18
                                                                         10                                                                                                                                  10
Mitsiriza
        56                48                               20
                                                                42                                                                             56             48                               20
                                                                                                                                                                                                    42
                                                  14        31 11              12         41                                                                                          14        31 11              12         41
                    47                 15             40 16                                                                                             47
                                                                                                               44                                                          15             40 16
                                                                    13         34                                                                                                                                  34                             44
                                    6            32                                                                                                                                  32                 13
                                                                                                                                                                        6
                                   5                       33                 17                                                                                       5                                          17
                                        4                                                  35                                                                                                  33
                         9                                                                                                                                                  4                                                  35
                                                  2                                                                                                          9
                                                                    7                                                                                                                 2
           46                                                                                                                                                                                           7
                                                                                                                                              46
                               3                                              21                                                                                                                                  21
                                                                                                                                                                   3
                                                                8                                                                                                                                   8
                                        37            1                                                                                                                                   1
                                                                                                                                                                            37
      57                                                            22                                                                   57                                                             22

                                                                                     23                                                                                                                                  23
                45                                36                                                                                                45                                36

                                                                         24    Ngwenya                                                                                                                       24



                                                                                    38                                                                                                                                  38
  0    1    2   3        4     5 Kilometers                                                                                          0    1    2    3        4     5 Kilometers



      STOP TB Symposium 2009                                                                                                                                                                                                                                    6
The relationship between poverty and TB


The poor have

• higher risk of infection

• higher prevalence of
  disease

• worse outcome of
  disease




STOP TB Symposium 2009                    7
Conceptual framework for improved and
   early case notification/detection



                          Symptoms     Patient   Health care
                          recognised    delay     utilisation




 Active TB                                                      Diagnosis



 Infected                                                       Notification




 STOP TB Symposium 2009                                                        8
Economic Hurdles faced by an average rural
resident accessing TB treatment in Malawi: 2004-5

         7.00                                              NB: no user fees
                                                           in public health
         6.00                                              facilities

         5.00


         4.00
   US$




         3.00                                       Total income
                                                    Food
                                                    Transport
         2.00
                                                    Drugs
                                                    Fees
         1.00


         0.00


                                                     Source:
                                                     Gillian Mann
                                                     PhD Thesis
                                                     University of Liverpool
                                                     2008

STOP TB Symposium 2009                                                    9
Potential effect of adding user-fees in public
health system

         7.00


         6.00


         5.00


         4.00
   US$




         3.00                                    Total income
                                                 Food
                                                 Transport
         2.00
                                                 Drugs
                                                 Fees
         1.00


         0.00




STOP TB Symposium 2009                                          10
          DOTS since     DOTS since
          2002           1992
STOP TB Symposium 2009                11
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)




STOP TB Symposium 2009                                        12
     http://www.who.int/tb/dots/laboratory/policy/en/index.html
    Categorising Patients


                                 3 consecutive smears                         2 consecutive
                                                                                 smears
                                                                           (high workload and
                                                                             HR constraints)
    Positive                   ≥+ in at least 2 smears                        ≥scanty in at
                                                                             least 1 smear
                                                                              (assured QA)
    Negative                    0 in at least 3 smears                       0 in at least 2
                                                                                smears

                         Several              Or                 0r
    Indeterminate        possibilities eg:-   + in less than 2   0 in 2
                                                                             0 in only one
                         Scanty in 2          smears             smears          smear
                         smears or less                          or less



STOP TB Symposium 2009                                                                          13
                           DAY 1                                 Patient
                                                                 screening
                                          Fails inclusion
                                          criteria

                         Excluded
                                             Does not           Informed
 Cuevas L et al                              accept             consent

 submitted                                                   Clinical
                                                             examination

                                                             Spot sputum
 6682 patients                                                               Frontloaded
                                      randomization
 Nigeria
 Yemen                                                                        Spot sputum (1 hour)
                          Standard
 Ethiopia
                                                                      Time           Result
 Nepal                                                                               s

                           DAY 2
                                          Morning smear                       Morning smear


                                          Spot sputum


                               Time              Result
                                                 s

                                                            Culture


STOP TB Symposium 2009                                                                               14
Figure 3. Sensitivity of the frontloaded and standard schemes when
examining 1, 2 or 3 smears. Error bars are 95% confidence interval.


                                                          p = 0.6                   p < 0.01

                              80                   p = 0.01                 p = 0.03

                                        p = 0.08                     p = 0.65                  p = 0.8
                                                       p = 0.4
             Sensitivity (95% CI)




                              70




                              60

                                                                                                               Frontloaded
                                                                                                               Standard
                              50




                              40




                              30
                                    3-smears                         2-smears                        1-smear
                                                                 Number of smears
 STOP TB Symposium 2009                                                                                                      15
Economic Hurdles faced by an average rural
resident accessing TB treatment in Malawi: 2004-5

         7.00                                              NB: no user fees
                                                           in public health
         6.00                                              facilities

         5.00


         4.00
   US$




         3.00                                       Total income
                                                    Food
                                                    Transport
         2.00
                                                    Drugs
                                                    Fees
         1.00


         0.00


                                                     Source:
                                                     Gillian Mann
                                                     PhD Thesis
                                                     University of Liverpool
                                                     2008

STOP TB Symposium 2009                                                   16
Potential effect of front-loading of sputum
collection for smear microscopy (2 specimens
only)

          7.00


          6.00


          5.00


          4.00
    US$




          3.00                                 Total income
                                               Food

          2.00                                 Transport
                                               Drugs
                                               Fees
          1.00


          0.00




STOP TB Symposium 2009                                        17
Potential effect of frontloading (2 specimens)
with same-day issue of results

         7.00


         6.00


         5.00


         4.00
   US$




         3.00                                    Total income
                                                 Food
         2.00                                    Transport
                                                 Drugs

         1.00                                    Fees


         0.00




STOP TB Symposium 2009                                          18
Potential effect of front-loading (2
specimens), same day results and working
with informal providers for referral

          7.00


          6.00


          5.00


          4.00
    US$




          3.00                             Total income
                                           Food
                                           Transport
          2.00
                                           Drugs
                                           Fees
          1.00


          0.00




STOP TB Symposium 2009                                    19
A Framework for Impact Assessment for New Diagnostics
Layer of Assessment      Kinds of question(s) being answered

Layer 1:                 How well does new tool work in terms of accuracy?
EFFICACY ANALYSIS        How many additional cases will be identified who would otherwise not have been identified?
                         How many additional cases will actually start treatment as a result of using new tool?
Layer 2:                 Who benefits from new tool? (ambulant vs hospitalised, poor/less poor, men/women,
EQUITY ANALYSIS            adults/children)
                         Why do these benefits accrue? (level health system in which LPAs are deployed, change time
                           to issue of results, change in patient costs)
Layer 3:                 What are the human resource implications of introducing new tool? (training, number and
HEALTH SYSTEM ANALYSIS     cadre of staff)
                         What are the infrastructure implications? (equipment, lab layout, safety installations)
                         What are the procurement implications? (reagents, consumables, documentation)
                         What are the implications for quality assurance? (internal and external)
Layer 4:                 What are the projected impacts of going to scale with new tool? eg
SCALE UP ANALYSIS        a) cost savings to patients in relation to income
                         b) cost savings to health providers / the health system
                         d) Effects on transmission of improved infection control as a result of new tool

Layer 5:                 What other similar technologies are available or likely to become available?
POLICY ANALYSIS          How do similar existing or emerging technologies compare in their projected performance
                           within each of the layers above?




STOP TB Symposium 2009                                                                                                20
The contribution of research - Conclusions

1. Improved understanding of the concept of poverty

2. Improved understanding of the relationship between poverty
   and TB

3. Documenting the barriers (hurdles) faced by poor patients
   accessing TB Services

4. Identifying, piloting, and assessing the impact of ways of
   overcoming access hurdles

5. Ensuring that the poor are not forgotten in New Tools
   Research



STOP TB Symposium 2009                                          21
The contribution of research – what next?

1. More commitment from funders for poverty focussed action
   research (Many thanks to LHL, TDR, DFID, USAID)

2. More engagement of patients and communities in the research
   process

3. Going to scale with innovations




STOP TB Symposium 2009                                           22
            B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71
STOP TB Symposium 2009                                        23
An example of a quantitative proxy
measure




            B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71
STOP TB Symposium 2009                                        24
An example of a qualitative matrix




            B. Nhlema-Simwaka et al, IJTLD 2007;11(1):65-71
STOP TB Symposium 2009                                        25

				
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