Improving Access to DOTS for the poor in Malawi

Julia Kemp, Gillian Mann, Bertha Nhlema, Felix Salaniponi, and Bertie Squire

Equi-TB Knowledge Programme &National TB Programme, Malawi

TB control in Malawi

Malawi has run a comprehensive DOTS programme since 1984

One of the first countries to pioneer the WHO recommended ‘DOTS’ strategy

National DOTS coverage –integrated throughout the health system, including public & private providers

Free consultation and diagnosis in Public facilities and free drug treatment

Programme indicators:•Total cases 26,532 = ~226/100,000 case notification rate (2002)•Cure rate 67% (2002)•Default 6% and transfer out 3% (2002)

Despite a devastating national HIV epidemic•77% TB cases are HIV+ (1999)•TB case fatality 19% (2002)

Do the poor have access to DOTS in Malawi?

1999 NTP embarked on a new initiative to assess whether the DOTS programme reaches the poor

Equi-TB Knowledge Programme• Aim to promote access to care, particularly for the poorest• Inter-disciplinary research, drawing upon a range of

research methods, highlighting the patient & community perspectives on TB control

• Collaboration between NTP, University of Malawi and Liverpool School of Tropical Medicine

Methodology

A number of different studies focusing on a range of equity issues

Presented Here:• Random sample of 179 new pulmonary TB patients at 6

health facilities in Lilongwe• Poverty assessment tool developed and tested, based

regression analysis of the 1998 Integrated Household Survey

• Tool applied to assess poverty status of the sample• Individual In-depth interviews to assess impact of TB on

livelihoods

Characteristics of the Poor

Poor people were characterised as: Living in poorly ventilated and constructed houses Having few assets Earning income from casual labour (ganyu), petty trading, or

unskilled labour Being food insecure

Non-poor people were characterised as: Having adequate food Earning income from medium or large scale businesses,

working in the public and private sectors Living in better houses (e.g. having an iron-sheet roof)

Poverty Status of TB Patients

TB patients who make it into the DOTS programme in Lilongwe are poorer than the general population

62% patients within the sample were poor (95% CI: 55-69%)

The general urban population Lilongwe poverty headcount 37.8% (IHS)

The impact of TB is greatest on the poor

Poor patients engage in impoverishing coping strategies: Sold assets (such as pots and pans) Lost income dependant on the daily input of labour Took on local loans at a high interest rate Missed meals or were unable to purchase tap water from the

communal tap

Non-poor patients were able to mitigate the economic impact of the illness by drawing upon savings or valuable assets.

Both poor and non-poor experienced negative consequences of TB BUT the effect was greater on poor TB patients

Evidence that TB cases are ‘missing’ from the poorest areas in Lilongwe? A comparison of Area 18 with Area 56

Area 18

High density, planned settlement

Area 56 – Mtsilisa and Ntandile

High density, unplanned “squatter” settlement

Note: areas are adjacent

How many missing TB cases in the poorest areas?

Area 18 Area 56 Missing

Population 10,677 22,369

Pop density (pop/sq.km) 3,568 3,158

Chronic cough cases 254 182

Smear positive TB cases 41 44

Chronic cough/100,000 2379 814 1565

Smear positive TB/100,000 384 197 187

Actual number of missing chronic cough cases – 350

Actual number of missing smear positive TB cases – 42

Half of all smear positive cases of TB may be missing from the poorest areas

How much does it cost for a TB diagnosis in Lilongwe?

Costs are both direct (cash expenditure) and indirect (use of non-cash resources)

Cash spent on transport, fees and food for patient and guardian

Men reported more time off work • Higher opportunity costs (but reproductive labour difficult to cost)

Women’s labour more likely to be replaced by someone else• Labour mostly replaced by girl children – future impact?

Relatively high cost for a TB diagnosis for the poor in Lilongwe (US$)

All Patients All poor

All non-poor

Direct Costs of Pathway to CareFees and Drugs 7.6 6.6 9.8Transport 3.4 2.6 5.6Food 2.0 1.8 2.3

Total Direct Costs 13.0 11.0 17.7

Opportunity CostsDays Lost (days) 22.1 21.9 23.2Mean income (IHS) $0.71 $0.21 $1.23

Income lost during care seeking $16 $5 $29

Total Costs $29 $16 $46

Total costs as % of monthly income 134% 248% 124%

% income not spent on food 65% 42% 70%

Total costs as % of monthly income after food expenditure 206% 584% 176%

Note:n=179 patients

Poverty measured against Integrated Household Survey (IHS)

TB diagnosis is free in all public and mission facilities

All people live within 6km of a public health facility in urban Lilongwe

Policy responsiveness of NTP to findings on equity in access to TB care

New Five Year Development Plan (2002-2006) Testing of interventions to shorten diagnosis pathways for

poor communities• Store keepers initiative with poor communities in an urban setting• Community-based case-finding strategies

Improving overall quality of TB services to reduce diagnostic delays

New communication strategy• Using targeted methods and messages for poor populations

Developing better monitoring and evaluation, integrating patient and community perspectives

Understanding delays in accessing care in Rural Malawi