Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance.

BACKGROUND: Vietnam's primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process. METHODS: A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated. RESULTS: We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers. CONCLUSIONS: Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

Evaluation of a population-wide, systematic screening initiative for tuberculosis on Daru island, Western Province, Papua New Guinea.

BACKGROUND: A population-wide, systematic screening initiative for tuberculosis (TB) was implemented on Daru island in the Western Province of Papua New Guinea, where TB is known to be highly prevalent. The initiative used a mobile van equipped with a digital X-ray device, computer-aided detection (CAD) software to identify TB-related abnormalities on chest radiographs, and GeneXpert machines for follow-on diagnostic testing. We describe the results of the TB screening initiative, evaluate its population-level impact and examine risk factors associated with TB detection. METHODS: Through a retrospective review of screening data, we assessed the effectiveness of the screening by examining the enrolment coverage and the proportion of people with TB among screened subjects. A cascade analysis was performed to illustrate the flow of participants in the screening algorithm. We conducted univariate and multivariate analyses to identify factors associated with TB. Furthermore, we estimated the number of additional cases detected by the project by examining the trend of routine TB case notifications during the intervention period, compared to the historical baseline cases and trend-adjusted expected cases. RESULTS: Of the island's 18,854 residents, 8,085 (42.9%) were enrolled and 7,970 (98.6%) had chest X-ray interpreted by the CAD4TB software. A total of 1,116 (14.0%) participants were considered to have abnormal CXR. A total of 69 Xpert-positive cases were diagnosed, resulting in a detection rate of 853 per 100 000 population screened. 19.4% of people with TB had resistance to rifampicin. People who were in older age groups (aOR 6.6, 95%CI: 1.5-29.1 for the 45-59 age group), were severely underweight (aOR 2.5, 95%CI:1.0-6.1) or underweight (aOR 2.1, 95%CI: 1.1-3.8), lived in households < 5 people (aOR 3.4, 95%CI:1.8-6.6) and had a past history of TB (aOR 2.1, 95%CI: 1.2-3.6) were more likely to have TB. The number of bacteriologically confirmed TB notified during the intervention period was 79.3% and 90.8% higher than baseline notifications and forecasted notifications, respectively. CONCLUSION: The screening project demonstrated its effectiveness with the high Xpert-positive TB prevalence among the participants and by successfully yielding additional cases of bacteriologically confirmed TB including rifampicin-resistant TB. The results and lessons learnt from the project should inform future TB screening initiatives in Papua New Guinea.

Will more sensitive diagnostics identify tuberculosis missed by clinicians? Evaluating Xpert MTB/RIF testing in Guatemala / ¿Pueden las pruebas diagnósticas más sensibles identificar los casos de tuberculosis que se escapan a los clínicos? Evaluación de Xpert MIB/RIF en Guatemala

OBJECTIVE: To assess the impact of introducing Xpert as a follow-on test after smear microscopy on the total number pulmonary TB notifications. METHOD: Genexpert systems were installed in six departments across Guatemala, and Xpert was indicated as a follow-on test for people with smear-negative results. We analyzed notifications to national tuberculosis (TB) programmes (NTP) and the project's laboratory data to assess coverage of the intervention and case detection yield. Changes in quarterly TB notifications were analyzed using a simple pre/post comparison and a regression model controlling for secular notification trends. Using a mix of project and NTP data we estimated the theoretical yield of the intervention if testing coverage achieved 100%. RESULTS: Over 18,000 smear-negative individuals were eligible for Xpert testing during the intervention period. Seven thousand, one hundred and ninety-three people (39.6% of those eligible) were tested on Xpert resulting in the detection of 199 people with smear-negative, Xpert positive results (2.8% positivity rate). In the year before testing began 1098 people with smear positive and 195 people with smear negative results were notified in the six intervention departments. During the intervention, smear-positive notification remained roughly stable (1090 individuals, 0.7%), but smear-negative notifications increased by 167 individuals (85.6%) to an all-time high of 362. After controlling for secular notifications trends over an eight-quarter pre-intervention period, combined pulmonary TB notifications (both smear positive and negative) were 19% higher than trend predictions. If Xpert testing coverage approached 100% of those eligible, we estimate there would have been a+41% increase in TB notifications. CONCLUSIONS: We measured a large gain in pulmonary notifications through the introduction of Xpert testing alone. This indicates a large number of people with TB in Guatemala are seeking health care and being tested, yet are not diagnosed or treated because they lack bacteriological confirmation. Wider use of more sensitive TB diagnostics and/or improvements in the number of people clinically diagnosed with TB have the potential to significantly increase TB notifications in this setting, and potentially in other settings where a low proportion of pulmonary notifications are clinically diagnosed

OBJETIVO: Evaluar el impacto en la notificación de casos de tuberculosis pulmonar de la introducción de Xpert como prueba de continuación después del análisis microscópico. MÉTODO: Se instalaron sistemas Genexpert es seis departamentos de Guatemala y se indicó como prueba consecutiva en todos los resultados negativos en la baciloscopia microscópica. Se analizaron los datos del Programa Nacional y los del laboratorio del proyecto para medir la cobertura y la productividad en detección de casos. Las notificaciones trimestrales se compararon con los valores anteriores a la intervención y se adoptó un modelo de regresión para controlar por las tendencias temporales. Se estimó la contribución teórica de la intervención en términos de notificación si se obtuviera una cobertura del 100%. RESULTADOS: Durante el período de intervención, más de 18.000 personas con baciloscopia negativa fueron elegibles en los seis departamentos. El esputo de 7193 (36,9%) de ellos fue analizado también por Xpert y se detectaron 199 personas con baciloscopia negativa y Xpert positivo (positividad: 2,8%). En el año anterior a la intervención se notificaron 1098 casos de tuberculosis pulmonar y baciloscopia positiva, y 195 con baciloscopia negativa. Durante la intervención, la notificación de casos con baciloscopia positiva se mantuvo estable (1090 personas, 0,7%), pero las notificaciones con baciloscopia negativa, que incluía los casos con baciloscopia negativa y Xpert positivo, aumentó en 167 casos (85,6%), llegando a los 362 casos. Después de controlar por la tendencia temporal de notificación en los ocho trimestres anteriores, la notificación de tuberculosis pulmonar (con baciloscopia positiva o no) fue un 19% mayor que las predicciones de la tendencia. Si la cobertura de Xpert se acercase al 100%, se estima que se habría producido un incremento del 41% en las notificaciones. CONCLUSIONES: Se identifica un importante aumento de las notificaciones de tuberculosis pulmonar solo con la introducción de Xpert. Ello indica que un número importante de personas con tuberculosis en Guatemala son atendidos por los servicios de salud y son sometidos a bacteriología microscópica, pero no son diagnosticados ni tratados porque no disponen de confirmación bacteriológica. La utilización de técnicas diagnósticas más sensibles o la mejora en el diagnóstico clínico tienen potencial para aumentar significativamente las notificaciones de tuberculosis pulmonar en esta zona y en cualquier otro lugar donde exista una proporción baja de diagnósticos clínicos no confirmados por microscopía