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. 2011 Jan 18:11:43.
doi: 10.1186/1471-2458-11-43.

Assessing access barriers to tuberculosis care with the tool to Estimate Patients' Costs: pilot results from two districts in Kenya

Verena Mauch  1 , Naomi Woods, Beatrice Kirubi, Hillary Kipruto, Joseph Sitienei, Eveline Klinkenberg
Affiliations

Assessing access barriers to tuberculosis care with the tool to Estimate Patients' Costs: pilot results from two districts in Kenya

Verena Mauch et al. BMC Public Health. .

Abstract

Background: The poor face geographical, socio-cultural and health system barriers in accessing tuberculosis care. These may cause delays to timely diagnosis and treatment resulting in more advanced disease and continued transmission of TB. By addressing barriers and reasons for delay, costs incurred by TB patients can be effectively reduced. A Tool to Estimate Patients' Costs has been developed. It can assist TB control programs in assessing such barriers. This study presents the Tool and results of its pilot in Kenya.

Methods: The Tool was adapted to the local setting, translated into Kiswahili and pretested. Nine public health facilities in two districts in Eastern Province were purposively sampled. Responses gathered from TB patients above 15 years of age with at least one month of treatment completed and signed informed consent were double entered and analyzed. Follow-up interviews with key informants on district and national level were conducted to assess the impact of the pilot and to explore potential interventions.

Results: A total of 208 patients were interviewed in September 2008. TB patients in both districts have a substantial burden of direct (out of pocket; USD 55.8) and indirect (opportunity; USD 294.2) costs due to TB. Inability to work is a major cause of increased poverty. Results confirm a 'medical poverty trap' situation in the two districts: expenditures increased while incomes decreased. Subsequently, TB treatment services were decentralized to fifteen more facilities and other health programs were approached for nutritional support of TB patients and sputum sample transport. On the national level, a TB and poverty sub-committee was convened to develop a comprehensive pro-poor approach.

Conclusions: The Tool to Estimate Patients' Costs proved to be a valuable instrument to assess the costs incurred by TB patients, socioeconomic situations, health-seeking behavior patterns, concurrent illnesses such as HIV, and social and gender-related impacts. The Tool helps to identify and tackle bottlenecks in access to TB care, especially for the poor. Reducing delays in diagnosis, decentralization of services, fully integrated TB/HIV care and expansion of health insurance coverage would alleviate patients' economic constraints due to TB.

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Figures

Figure 1
Figure 1
Diagnosis and Treatment Algorithm. In 2008/2009, the Kenyan TB program has changed its treatment regimen from an eight-month to a six-month regimen. Retreatment cases receive an eight-month regimen. Abbreviations: AFB: Acid-Fast Bacili; PTB: Pulmonary Tuberculosis; EPTB: Extra-Pulmonary Tuberculosis
Figure 2
Figure 2
Household asset ownership at time of interview.
Figure 3
Figure 3
Household monthly income groups before and after onset of TB. Reported quintiles are those of the study population.
Figure 4
Figure 4
Individual monthly income groups before and after onset of TB.
Figure 5
Figure 5
Monthly household food expenditures by income group.
Figure 6
Figure 6
Total direct and indirect costs by gender as% of monthly individual income.
See this image and copyright information in PMC

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