title: Social protection and tuberculosis control in 21 European countries, 1995-2012: a cross-national statistical modelling analysis.
abstract: BACKGROUND
  WHO stresses the need to act on the social determinants of tuberculosis. We tested whether alternative social protection programmes have affected tuberculosis case notifications, prevalence, and mortality, and case detection and treatment success rates in 21 European countries from 1995 to 2012.
  
  
  METHODS
  We obtained tuberculosis case notification data from the European Centre for Disease Prevention and Control's 2014 European Surveillance System database. We also obtained data for case detection, treatment success, prevalence, and mortality rates from WHO's 2014 tuberculosis database. We extracted data for 21 countries between Jan 1, 1995, and Dec 31, 2012. Social protection data were from EuroStat, 2014 edition. We used multivariate cross-national statistical models to quantify the association of differing types of social protection programmes with tuberculosis outcomes. All analyses were prespecified.
  
  
  RESULTS
  After we controlled for economic output, public health spending, and country fixed effects, each US$100 increase in social protection spending was associated with a decrease per 100,000 population in the number of tuberculosis case notifications of -1·53% (95% CI -0·28 to -2·79; p=0·0191), estimated incidence rates of -1·70% (-0·30 to -3·11; p=0·0201), non-HIV-related tuberculosis mortality rate of -2·74% (-0·66 to -4·82; p=0·0125), and all-cause tuberculosis mortality rate of -3·08% (-0·73 to -5·43; p=0·0127). We noted no relation between increased social spending and tuberculosis prevalence (-1·50% [-3·10 to 0·10] per increase of $100; p=0·0639) or smear-positive treatment success rates (-0·079% [-0·18 to 0·34] per increase of $100; p=0·5235) or case detection (-0·59% [-1·31 to 0·14] per increase of $100; p=0·1066). Old age pension expenditure seemed to have the strongest association with reductions in tuberculosis case notification rates for those aged 65 years or older (-3·87% [-0·95 to -6·78]; p=0·0137).
  
  
  CONCLUSIONS
  Investment in social protection programmes are likely to provide an effective complement to tuberculosis prevention and treatment programmes, especially for vulnerable groups.
  
  
  BACKGROUND
  European Centre for Disease Prevention and Control.
authors.affiliation: Department of Sociology, University of Oxford, Oxford, UK. Electronic address: aaron.reeves@sociology.ox.ac.uk.
authors.forename: Aaron
authors.initials: A
authors.lastname: Reeves
authors.affiliation: School of Medicine, Stanford University, Palo Alto, CA, USA.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Basu
authors.affiliation: European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: McKee
authors.affiliation: Department of Sociology, University of Oxford, Oxford, UK.
authors.forename: David
authors.initials: D
authors.lastname: Stuckler
authors.affiliation: European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
authors.forename: Andreas
authors.initials: A
authors.lastname: Sandgren
authors.affiliation: European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
authors.forename: Jan
authors.initials: J
authors.lastname: Semenza
mesh_terms: D005060:Europe / Q000453:epidemiology; D006801:Humans; D015995:Prevalence; D011640:Public Policy / Q000191:economics*; D016019:Survival Analysis; D016896:Treatment Outcome; D014376:Tuberculosis / Q000188:drug therapy / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control*