Determinants of household costs and access to care for tuberculosis in Tajikistan

This thesis investigated access to medical care for tuberculosis (TB). TB is among the worst infectious diseases globally, causing about 2 million deaths per year. TB control will not be possible, if the most vulnerable do not have access to appropriate treatment. Studies for the present thesis were carried out in Tajikistan, one of the poorest countries of the world. The health system of Tajikistan is firmly rooted in its Soviet history with a dense network of facilities and allegiances to separate vertical programs for different tasks of the health system.
The seven studies in this thesis used qualitative and quantitative methods to investigate access to care. The first study, using focus groups, found that community members, TB patients and health care providers all considered economic factors the most important barriers to medical care.
A subsequent study investigated delay to TB treatment. Generally moderate delays (median 52 days) until start of TB treatment were found. However, two subgroups of patients had long health system delays. These were the patients who first presented to peripheral primary care facilities and especially those who developed active disease while working in Russia. The long delays of the former are related to the vertical structure of TB control inherited from Soviet times: primary care providers were reluctant to diagnose TB. Diagnosis at the primary care level based on sputum smear microscopy should be promoted to shorten the delays of these patients. For labour migrants developing active TB in Russia, an international referral system is needed, including availability of treatment until sputum conversion for Tajik citizens in Russia.
The third study investigated illness-related costs at the level of the patients’ households. Mean self-reported total costs of an episode of TB were USD1’053, or c. USD4’900 purchasing power parity. The costs peaked before starting TB treatment and in the intensive phase of TB treatment. Hence, the costs of an episode of TB are catastrophic and both strategies to reduce costs and strategies to help patients cope with costs are urgently needed. These strategies should be timed early in treatment in order to correspond with the highest cost peak.
The fourth study identified factors associated with higher expenditure for TB. It further investigated coping strategies that may lead to impoverishment: selling productive assets and borrowing money. Receiving ‘additional medication’ predicted higher direct costs. Further significant predictors were the delay until start of TB treatment and hospitalisation. TB patients raised on average USD182 through selling productive assets and through borrowing. Based on the results, it was suggested that ‘additional treatment’ should be diminished to reduce costs for patients. The potentially detrimental coping strategies employed confirm the severe economic burden that TB patients carry.
The fifth study used data from the TB registry to identify predictors of hospitalisation and positive treatment outcomes. Sputum smear result was the most important predictor of hospitalisation, with age and sex being further significant factors. Treatment success was significantly lower for sputum-smear positive patients and there was a tendency for lower treatment success among hospitalised patients. It is recommended that national guidelines be adapted to emphasise outpatient treatment.
A survey among patients found that a considerable proportion of TB patients had already received the three food supplements that they are entitled to – before the end of the treatment. Food supplements made a contribution of about USD225 to the household economy.
Bayesian modelling of the sensitivity of routine sputum smear microscopy in peripheral laboratories in Tajikistan yielded an estimate of sensitivity of 53% for the examination of a single slide. The contribution of the third slide to total case finding through sputum microscopy was estimated at 13%. These results suggest that the third serial sputum specimen could make a substantial contribution to case finding, if it were carried out with equal quality as previous examinations. The sensitivity of routine sputum microscopy in the studied districts is reasonably good and its use should be promoted. Concurrently, strengthening of the quality assurance should continue.
The present thesis found that an analytical framework for access to care, developed in the context of a malaria control program, is useful also in the area of TB. Adaptations to make the analytical framework fit better to the context of access to TB care are suggested. This thesis identified economic factors as the main barriers to access medical care for TB. Several characteristics of health care delivery rooted in the Soviet health system contributed to the high costs faced by patients and to the long delays until treatment experienced by certain subgroups of patients. The importance of factors related to the Soviet history of health care suggests that many of our findings may also apply to other post-Soviet countries.
In order to improve access to TB care and hence TB control in Tajikistan, the economic burden for the patients must be reduced as a matter of priority. Further, the long delays of certain subgroups of patients need to be shortened. The latter can be achieved more easily than the former, among others by improving referral systems and by promoting the use of sputum smear microscopy. Reducing the economic burden for TB patients requires measures on both sides: reducing the costs faced by patients and increasing their ability to cope with these costs. Collaboration between the health system, non-governmental organisations and funding agencies as well as between different programs within the health system, like the TB control program and primary care, will be necessary.