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Addressing Poverty and Tuberculosis: A Global Overview with Focus on Kenya

This presentation explores the intersection of poverty and tuberculosis (TB), emphasizing its global impact, particularly in Kenya. TB remains a leading cause of death among those living with HIV in Africa. With 8.8 million new cases reported in 2003 and a notable link between poverty and TB incidence, the need for effective treatment strategies like the DOTS program is urgent. The discussion also highlights challenges such as low case detection rates, the dual epidemic of TB and HIV, and the socioeconomic factors exacerbating the TB crisis, especially among marginalized populations.

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Addressing Poverty and Tuberculosis: A Global Overview with Focus on Kenya

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  1. Poverty & TB: Global Overview and Kenyan case study Christy Hanson, PhD, MPH PATH May 30, 2005 CCIH Annual Conference

  2. Global TB Control: TB facts • TB is infectious, curable disease • 8.8 million new cases of TB in 2003 • TB is the primary cause of death for PLWHA in Africa • Highly cost-effective treatment strategy • Only half of new cases were detected in 2003

  3. per 100 000 population < 10 10 to 24 25 to 49 50 to 99 100 to 299 300 or more No Estimate Estimated TB incidence rates 2003

  4. TB and HIV: Overlapping epidemics TB infected (1.7 billion) HIV at risk (?) HIV (+) (40 m) Active TB (8.8 m per year) HIV (+) with Active TB (0.7 m)

  5. HIV prevalence in TB cases, 15-49 yrs (%) < 5 5 - 19 20 - 49 50 or more No estimate Estimated HIV Prevalence in TB cases, 2002 Global Tuberculosis Control. WHO Report 2003. WHO/HTM/TB/2004.331

  6. Africa: HIV driving the TB epidemicTB notification rates, 1980-2003 Source: WHO reports

  7. 700 0.16 0.14 600 0.12 500 0.10 400 0.08 300 0.06 200 0.04 100 0.02 0 0.00 1980 1990 2010 2000 TB and HIV in Kenya HIV prevalence TB incidence

  8. Global Targets for TB control • 70% case detection • 85% treatment success

  9. TB can be cured: DOTS strategy • Political commitment • Standardized treatment regimen • Available free of charge to patients in public sector • Diagnosis by smear microscopy • Directly-observed treatment (DOT) • Standardized recording and reporting • Quality control

  10. DOTS Works • China • DOTS areas: 44% decrease in TB prevalence (1990-2000) • Non-DOTS areas: 12% decrease in TB prevalence • Global level • DOTS areas: treatment success rates average 80% • Non-DOTS areas: around 50%

  11. Evolution of DOTS Broaden ownership: private sector, partners Emerging threats: TB/HIV, MDR-TB Building political commitment New tools: diagnostics, drugs Increase case detection Resource mobilization Widescale training Health sector reform Adoption of DOTS “DOTS” brand Model developed in Africa; Karel Styblo 1995 2005 Adopting DOTS Expanding DOTS Adapting DOTS

  12. Number of countries implementing DOTS, 1990 - 2003 Total number of countries 200 150 Number of countries 100 50 0 1990 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295

  13. Challenges for the future of TB control • Dual epidemic of TB/HIV • Low case detection rates Possible cause: not reaching the poor?

  14. Poverty: Inequity between countries

  15. Distribution of Poverty Source: World Bank, WDR 2000

  16. Causes of Poor-Rich Health Status Gap Non-Communicable Diseases – 15% Injuries 8% Source: World Bank; Gwatkin, D.; 2000 Communicable Diseases 77% * “poor” and “rich” represent poorest countries / richest countries

  17. Disproportionate disease burden among the poor* Source: World Bank; Gwatkin, D.; 2000 * “poor” and “rich” represent poorest countries / richest countries

  18. 22 Highest TB burden countries • None are high-income countries • 78% have GNP per capita of less than $760 (low income) • Estimate: over 50% new TB patients without access to DOTS are living on less than $2 per day

  19. Korea case study TB And Economic Development Per capita GNI 350 TB cases Korean War 49 TB deaths 7 NTP Unemployment rates

  20. Poverty: Inequity within countries

  21. TB prevalence among poor and non-poor, Philippines Source: Tupasi et. al.; IJTLD 4(12): 1126-1132

  22. TB and poverty: correlation in a high-income country

  23. TB in the homeless Source: Moss, Hahn, Tulsky et al.; Am J Respir Crit Care Med 2000 Annual incidence per 100,000 * Notified cases

  24. Poverty: Individual level

  25. Risk factors Risk factors Risk factors Risk factors TB Epidemiology Infectious TB Sub-clinical infection Cure, chronic or Death Exposure Non-infectious TB Source: adapted from Urban & Vogel; Am Rev Respir Dis 1981

  26. Income poverty and TB • The poor lack: • Food security • Income stability • Access to water, sanitation • Access to health care TB disease Income poverty • TB may lead to: • Loss of 20-30% of annual wages among poor

  27. Poverty links to TB exposure, infection and disease • Overcrowding • Malnutrition • TB anemia, low retinol & zinc, wasting • Vit D deficiency 10x risk of TB disease • Gender differentials • Higher prevalence among men • Women:faster breakdown to TB disease (2x) • Marginalized populations • Ethnicity • Prisoners

  28. TB case rates by SES indicator: United States 1987-1993 Source: Cantwell, McKenna, McCray, et al.; Am J Respir Crit Care Med, 1998

  29. Poverty & TB disease outcome • Impoverishing effects of TB • Economic: 20-30% of household wages • Social: stigma • Women fear social impoverishment, men fear economic • Delayed treatment seeking • Worse outcomes? • Barriers to access • Inhibited continuity • In absence of treatment, 50% will die

  30. Reasons for treatment delay: China Source: Ministry of Health, China; 1990 prevalence survey

  31. Global Response to Health Inequities • Millennium Development Goals • Halve the prevalence of TB disease and deaths between 1990 and 2015 • Poverty-Reduction Strategy Papers • Re-orienting development agenda toward pro-poor approaches • Debt-relief, increased funds for social sectors • Global Fund for AIDS, TB and malaria • 4 rounds of applications funded • over $8 billion approved • $1 billion for TB (13%)

  32. Financing public health: caring for the poor?

  33. Financial subsidy from Government health services to poorest & richest 20% Source: World Bank, 2001

  34. Expenditures on TB care by level of wealth Sample of patients in Nairobi US$ Source: Hanson and Kutwa (unpublished)

  35. Mounting a response

  36. TB community response to TB and poverty • DOTS expansion and adaptation • Global TB Drug Facility • Stop TB Partnership • Collaboration with NGOs, partners • Social and resource mobilization • 2002 Theme: TB and poverty • Research • Benefit - incidence • Evaluating what works • Understanding what matters to the poor (demand)

  37. Addressing barriers to care: Examples • Cambodia: food incentives for all TB patients • Uganda: community-based care • China: increased financing for TB control in poorest areas • Kenya: mobile treatment facilities for migrant populations • Mauritania: salary supplements for health workers in poor, rural areas

  38. Kenyan Case Study Is the health system responding to poverty dimension of TB?

  39. Trends in Tuberculosis: Kenya • 46% of population lives in absolute poverty • >50% of TB patients are HIV+ Source: WHO reports: 1997, 1998, 1999, 2000,2001, 2002, 2003, 2004, 2005

  40. Evidence of link: TB incidence and poverty

  41. Evidence of link: TB incidence and poverty

  42. Study objectives • Current performance of health sector in reaching poor TB patients • Treatment seeking patterns of poor vs. non-poor • Identify provider and patient characteristics associated with utilization of DOTS providers

  43. Survey Tools n=3500 • Provider: costs, services, patient base • Individual • Demographic information • Health information • Symptoms, choice set • TB knowledge • Treatment-seeking behavior • Movement between formal, informal, private, public • Utilization and expenditures • Valuation • Inventory what is important in decision-making • Preferences

  44. Wealth of TB patients & poverty in their provinces

  45. Profile of TB patients treated in public and private sectors 3% of patients completing treatment are among the poorest

  46. Change in wealth profile along continuum of diagnosis & treatment Most poor Least poor Diagnosis Treatment completion

  47. Where patients go vs. Where the system provides DOTS

  48. Movement through the health system: the case of the poor • 40% start at decentralized dispensaries • Start at hospital level, 12% transition “backwards” • Less efficient transitioning • More visits (half had 5-10 visits, still not referred for dx) • More time ill • Higher expenditures • Most interact with a “DOTS” facility within 1st three visits, still don’t get referred for diagnosis • Individual & provider factors behind transitioning

  49. Conclusions & Next steps • TB patients actively seeking care • Poor disproportionately represented at all stages • Research: prevalence distribution by wealth • Social science research: why? • Private sector: competitive, well used • Cost & geographic access similar • District variance: lessons to be learned from successful districts • Modeling of system and district-level determinants impacting case detection • New initiatives: test strategies to reach the poor

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