Measuring Catastrophic Costs Due to Tuberculosis in Myanmar.

BACKGROUND: This is the first survey to use the World Health Organization (WHO) methodology to document the magnitude and main drivers of tuberculosis (TB) patient costs in order to guide policies on cost mitigation and to produce a baseline measure for the percentage of TB-affected households experiencing catastrophic costs in Myanmar. METHODS: A nationally representative cross-sectional survey was administered to 1000 TB patients in health facilities from December 2015 to February 2016, focusing on costs of TB treatment (direct and indirect), household income, and coping strategies. A total cost was estimated for each household by extrapolating reported costs and comparing them to household income. If the proportion of total costs exceeded 20% of the annual household income, a TB-affected household was deemed to have faced catastrophic costs. RESULTS: 60% of TB-affected households faced catastrophic costs in Myanmar. On average, total costs were USD 759, and the largest proportion of this total was accounted for by patient time (USD 365), followed by food costs (USD 200), and medical expenses (USD 130). Low household wealth quintile and undergoing MDR-TB treatment were both significant predictors for households facing catastrophic costs. CONCLUSIONS: The high proportion of TB-affected households experiencing catastrophic costs suggests the need for TB-specific social protection programs in patient-centered healthcare. The survey findings have led the government and donors to increase support for MDR-TB patients. The significant proportion of total spending attributable to lost income and food or nutritional supplements suggests that income replacement programs and/or food packages may ameliorate the burdensome costs.

Combined Tuberculosis and Diabetes Mellitus Screening and Assessment of Glycaemic Control among Household Contacts of Tuberculosis Patients in Yangon, Myanmar.

BACKGROUND: This study aimed to identify the prevalence of diabetes mellitus (DM) and tuberculosis (TB) among household contacts of index TB patients in Yangon, Myanmar. METHOD: Household contacts were approached at their home. Chest X-ray and capillary blood glucose tests were offered based on World Health Organization and American Diabetes Association guidelines. Crude prevalence and odds ratios of DM and TB among household contacts of TB patients with and without DM were calculated. RESULTS: The overall prevalence of DM and TB among household contacts were (14.0%, 95% CI: 10.6-18.4) and (5%, 95% CI: 3.2-7.6), respectively. More than 25% of DM cases and almost 95% of TB cases among household contacts were newly diagnosed. Almost 64% of known DM cases among household contacts had poor glycaemic control. The risk of getting DM among household contacts of TB patients with DM was significantly higher (OR-2.13, 95% CI: 1.10-4.12) than those of TB patients without DM. There was no difference in prevalence of TB among household contacts of TB patients with and without DM. CONCLUSION: Significant proportions of the undetected and uncontrolled DM among household contacts of index TB patients indicate a strong need for DM screening and intervention in this TB-DM dual high-risk population.

Different challenges, different approaches and related expenditures of community-based tuberculosis activities by international non-governmental organizations in Myanmar.

BACKGROUND: International non-governmental organizations (INGOs) have been implementing community-based tuberculosis (TB) care (CBTBC) in Myanmar since 2011. Although the National TB Programme (NTP) ultimately plans to take over CBTBC, there have been no evaluations of the models of care or of the costs of providing CBTBC in Myanmar by INGOs. METHODS: This was a descriptive study using routinely-collected programmatic and financial data from four INGOs during 2013 and 2014, adjusted for inflation. Data analysis was performed from the provider perspective. Costs for sputum examination were not included as it was provided free of charge by NTP. We calculated the average cost per year of each programme and cost per patient completing treatment. RESULTS: Four INGOs assisted the NTP by providing CBTBC in areas where access to TB services was challenging. Each INGO faced different issues in their contexts and responded with a diversity of strategies. The total costs ranged from US$ 140 754 to US$ 550 221 during the study period. The cost per patient completing treatment ranged from US$ 215 to US$ 1 076 for new cases and US$ 354 to US$ 1 215 for retreatment cases, depending on the targeted area and the package of services offered. One INGO appeared less costly, more sustainable and patient oriented than others. CONCLUSIONS: This study revealed a wide variety of models of care and associated costs for implementing CBTBC in diverse and challenging populations and contexts in Myanmar. Consequently, we recommend a more comprehensive evaluation, including development of a cost model, to estimate the costs of scaling up CBTBC country-wide, and cost-effectiveness studies, to best inform the NTP as it prepares to takeover CBTBC activities from INGOs. While awaiting evidence from these studies, model of CBTBC that have higher sustainability potential and allocate more resources to patient-centered care should be given priority support.

International non-governmental organizations' provision of community-based tuberculosis care for hard-to-reach populations in Myanmar, 2013-2014.

BACKGROUND: National tuberculosis (TB) programs increasingly engage with international non-governmental organizations (INGOs), especially to provide TB care in complex settings where community involvement might be required. In Myanmar, however, there is limited data on how such INGO community-based programs are organized and how effective they are. In this study, we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar, and assess their contribution to TB case detection. METHODS: We conducted a descriptive study using program data from four INGOs and the National TB Program (NTP) in 2013-2014. For each INGO, we extracted information on its approach and key activities, the number of presumptive TB cases referred and undergoing TB testing, and the number of patients diagnosed with TB and their treatment outcomes. The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships. RESULTS: All four INGOs implemented community-based TB care in challenging contexts, targeting migrants, post-conflict areas, the urban poor, and other vulnerable populations. Two recruited community volunteers via existing community health volunteers or health structures, one via existing community leaderships, and one directly involved TB infected/affected individuals. Two INGOs compensated volunteers via performance-based financing, and two provided financial and in-kind initiatives. All relied on NTP laboratories for diagnosis and TB drugs, but provided direct observation treatment support and treatment follow-up. A total of 21 995 presumptive TB cases were referred for TB diagnosis, with 7 383 (34%) new TB cases diagnosed and almost all (98%) successfully treated. The four INGOs contributed to the detection of, on average, 36% (7 383/20 663) of the total new TB cases in their respective townships (range: 15-52%). CONCLUSION: Community-based TB care supported by INGOs successfully achieved TB case detection in hard-to-reach and vulnerable populations. This is vital to achieving the World Health Organization End TB Strategy targets. Strategies to ensure sustainability of the programs should be explored, including the need for longer-term commitment of INGOs.