Someone with untreated tuberculosis (TB) will infect up to 14 others over a year. TB programmes must lower barriers to care-seeking to reduce this spread. From patients’ perspectives, barriers include treatment costs and travel. Proposed reforms to TB programmes in sub-Saharan Africa, including decentralisation, must consider each country's context to prevent negative impacts on care-seeking and under-funded primary health care services.

TB treatment is a very cost-effective health intervention in the developing world. Despite this, the disease kills almost two million adults each year. Many patients can spot the symptoms of TB and see the need for treatment, but socio-economic and cultural factors may prevent effective disease control.

In this study at the University of Zambia, interviews were conducted with 202 patients in 1996. These interviews revealed three themes underlying patient barriers to TB diagnosis:

• number of health care encounters and duration of illness prior to diagnosis
• financial constraints and unrecognised patient costs
• travel distances.

On average, patients have 6.7 health encounters over 63 days before being referred for TB diagnosis at the centralised government Chest Clinic. This period can involve self-treatment with ‘western’ or herbal remedies, or visits to traditional healers or private physicians. Even within the public sector, patients need to buy government-sponsored health insurance or pay a fee to receive a referral to the ‘free’ Chest Clinic. Confusion over how the referral system works is another important barrier.

There are unrecognised costs of seeking care, such as ‘special food’ and lost income. In addition, patients travelling to seek care spend 16 percent of their monthly income on transport. Others simply cannot get care if they are too ill to walk. Patients are often tempted to travel if they think that a more distant facility provides a better service or a more reliable drug supply.

These results have implications for the impact of reforms proposed for TB programmes in sub-Saharan Africa, particularly decentralisation. Under decentralisation, TB diagnosis occurs at neighbourhood clinics. This reduces the number of health encounters and travel distances involved. It may also cut congestion at larger hospitals with an opportunity to improve quality of care there. However, the extra burden of TB care may overstretch under-funded primary health services.

No single ideal decentralised design for TB treatment exits – each country must consider its own resources in the decision-making process. Two critical success factors are a minimum level of financial resources and infrastructure and parallel reform throughout the entire public sector. For successful decentralisation, the researchers recommend:

• accessing extra donor and private funding
• cutting costs by downsizing specialist hospital care
• reassessing the system of health referral
• providing education and financial or other incentives to all health care providers to refer patients to the TB programme
• redesigning TB clinic logistics to be more patient-friendly
• providing communication skills training for TB clinic staff.

Another proposed reform is the integration of TB programmes with other health services. TB programmes could offer access to free anti-TB drugs via private practitioners. They could also utilise the convenient location and familiarity of traditional healers. This potential reform will need ongoing education of private practitioners. Further integration of TB and HIV programmes may also be critical to reducing patient barriers to care-seeking. This could involve:

• community and volunteer involvement
• local income generation projects
• evaluation of cost savings from integration
• specific donor funding.

In much of sub-Saharan Africa, poorly resourced primary health care services are already under severe pressure. Any reform of TB programmes must be based upon a strengthening of the infrastructure and funding for local health care services to ensure that policies, such as decentralisation, do not harm care-seeking and the running of facilities.   

Source(s):
‘Patient care seeking barriers and tuberculosis programme reform: a qualitative study’, Health Policy 67: 93-106, by D. Needham, D. Bowman, S. Foster and P. Godfrey-Faussett, 2004
HINARI subscribers can access the full-text article here. Full document.

Funded by: Medical Research Council, Canada; AIDS Bureau, Ontario Ministry of Health, Canada; Ernst & Young Chartered Accountants; Commonwealth Foundation; Lennox-Boyd Memorial Trust; European Community; World Health Organisation; UK Department for International Development; Wellcome Trust; Beit Trust

id21 Research Highlight: 11 January 2005

Further Information:
Dale Needham
PO Box 266
Ilderton, Ontario
Canada NOM 2AO

Tel: +1 519 666 2784
Contact the contributor: dale.needham@utoronto.ca

University of Zambia

Other related links:
'Time lapse - delays in TB diagnosis in Zambia'

'Coughing up for TB tests - cost-effective diagnosis in Zambia'

'Far-fetched? Does travelling for treatment increase TB mortality risks?'

'What's the diagnosis? Testing for tuberculosis in Kenya'

'Diagnosing TB in Africa: the quest for cheaper methods'

'How many tests are enough? Testing for tuberculosis in Ethiopia'

'Test match: the search for a better test for TB infection'