Assessing access barriers to tuberculosis care with the tool to Estimate Patients' Costs: pilot results from two districts in Kenya.
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.
KNCV Tuberculosis Foundation, Den Haag, The Netherlands. mauchv@kncvtbc.nl
Verena
V
Mauch
Naomi
N
Woods
Beatrice
B
Kirubi
Hillary
H
Kipruto
Joseph
J
Sitienei
Eveline
E
Klinkenberg
D000293:Adolescent; D000328:Adult; D005260:Female; D006679:HIV Seropositivity / Q000150:complications; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics*; D054625:Healthcare Disparities / Q000191:economics*; D006801:Humans; D007182:Income; D007630:Kenya; D008297:Male; D010342:Patient Acceptance of Health Care; D010865:Pilot Projects; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000191:economics / Q000628:therapy*; D055815:Young Adult
Niger J Clin Pract. 2007 Dec;10(4):272-82
18293634
Bull World Health Organ. 2008 Nov;86(11):849-856
19030690
PLoS Med. 2006 Dec;3(12):e530
17194201
Lancet. 1996 Jul 13;348(9020):134-5
8676705
Int J Tuberc Lung Dis. 1999 Oct;3(10):869-77
10524583
Bull World Health Organ. 2007 Aug;85(8):580-5
17768515
Ann Med. 2003;35(4):235-43
12846265
Southeast Asian J Trop Med Public Health. 2002 Jun;33(2):321-30
12236432
BMC Public Health. 2007 Feb 08;7:19
17288593
Int J Tuberc Lung Dis. 1999 Jul;3(7):596-602
10423222
J Commun Dis. 2006 Mar;38(3):204-15
17373353
Lancet. 1999 Aug 14;354(9178):586-9
10470717
J Epidemiol Community Health. 2006 Jan;60(1):7-12
16361448
Am J Trop Med Hyg. 2004 Aug;71(2 Suppl):147-55
15331831
Int J Tuberc Lung Dis. 1997 Oct;1(5):485-6
9441109
Bull World Health Organ. 2005 Feb;83(2):118-26
15744404
Trop Med Int Health. 2001 Apr;6(4):256-9
11348515
J Epidemiol Community Health. 2000 May;54(5):381-7
10814660
BMJ. 1993 Sep 25;307(6907):759-61
8219945
J Epidemiol Community Health. 2006 Feb;60(2):95-101
16415256