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1.
Infect Dis Poverty ; 9(1): 14, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32019611

RESUMO

BACKGROUND: Despite the availability of free tuberculosis (TB) diagnosis and treatment, TB care still generates substantial costs that push people into poverty. We investigated out-of-pocket (OOP) payments for TB care and assessed the resulting economic burden and economic consequences for those with varying levels of household income in eastern China. METHODS: A cross-sectional study was conducted among TB patients in the national TB programme networks in eastern China. TB-related direct OOP costs, time loss, and coping strategies were investigated across households in different economic strata. Analysis of Variance was used to examine the differences in various costs, and Kruskal-Wallis tests were used to compare the difference in total costs as a percentage of annual household income. RESULTS: Among 435 patients, the mean OOP total costs of TB care were USD 2389.5. In the lower-income quartile, OOP payments were lower, but costs as a percentage of reported annual household income were higher. Medical costs and costs prior to treatment accounted for 66.4 and 48.9% of the total costs, respectively. The lower the household income was, the higher the proportion of medical costs to total costs before TB treatment, but the lower the proportion of medical costs patients spent in the intensive phase. TB care caused 25.8% of TB-affected households to fall below the poverty line and caused the poverty gap (PG) to increase by United States Dollar (USD) 145.6. Patients in the poorest households had the highest poverty headcount ratio (70.2%) and PG (USD 236.1), but those in moderately poor households had the largest increase in the poverty headcount ratio (36.2%) and PG (USD 177.8) due to TB care. Patients from poor households were more likely to borrow money to cope with the costs of TB care; however, there were fewer social consequences, except for food insecurity, in poor households. CONCLUSIONS: Medical and pretreatment costs lead to high costs of TB care, especially among patients from the poorest households. It is necessary to train health system staff in general hospitals to promptly identify and refer TB patients. Pro-poor programmes are also needed to protect TB patients from the medical poverty trap.


Assuntos
Gastos em Saúde , Seguro Saúde/economia , Pobreza , Tuberculose/economia , Adulto , China , Feminino , Financiamento Pessoal , Custos de Cuidados de Saúde , Humanos , Renda , Masculino , Fatores Socioeconômicos , Fatores de Tempo
2.
BMC Infect Dis ; 19(1): 1047, 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31823734

RESUMO

BACKGROUND: Molecular tests can allow the rapid detection of tuberculosis (TB) and multidrug-resistant TB (MDR-TB). TB-SPRINT 59-Plex Beamedex® is a microbead-based assay developed for the simultaneous spoligotyping and detection of MDR-TB. The accuracy and cost evaluation of new assays and technologies are of great importance for their routine use in clinics and in research laboratories. The aim of this study was to evaluate the performance of TB-SPRINT at three laboratory research centers in Brazil and calculate its mean cost (MC) and activity-based costing (ABC). METHODS: TB-SPRINT data were compared with the phenotypic and genotypic profiles obtained using Bactec™ MGIT™ 960 system and Genotype® MTBDRplus, respectively. RESULTS: Compared with MGIT, the accuracies of TB-SPRINT for the detection of rifampicin and isoniazid resistance ranged from 81 to 92% and 91.3 to 93.9%, respectively. Compared with MTBDRplus, the accuracies of TB-SPRINT for rifampicin and isoniazid were 99 and 94.2%, respectively. Moreover, the MC and ABC of TB-SPRINT were USD 127.78 and USD 109.94, respectively. CONCLUSION: TB-SPRINT showed good results for isoniazid and rifampicin resistance detection, but still needs improvement to achieve In Vitro Diagnostics standards.


Assuntos
Farmacorresistência Bacteriana , Citometria de Fluxo/métodos , Mycobacterium tuberculosis/genética , Tuberculose/diagnóstico , Antituberculosos/farmacologia , Proteínas de Bactérias/genética , Catalase/genética , Custos e Análise de Custo , RNA Polimerases Dirigidas por DNA/genética , Farmacorresistência Bacteriana/efeitos dos fármacos , Citometria de Fluxo/economia , Genótipo , Humanos , Isoniazida/farmacologia , Testes de Sensibilidade Microbiana , Mutação , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/isolamento & purificação , Regiões Promotoras Genéticas , Kit de Reagentes para Diagnóstico , Rifampina , Sensibilidade e Especificidade , Tuberculose/economia
3.
Rev Med Chil ; 147(8): 1042-1052, 2019 Aug.
Artigo em Espanhol | MEDLINE | ID: mdl-31859970

RESUMO

BACKGROUND: Recent data suggest an increase in tuberculosis (TB) incidence in Chile. AIM: To evaluate recent epidemiological trends, geographic extension and potential factors associated with TB reemergence in Chile. MATERIAL AND METHODS: Data analysis from official sources and trend analysis. RESULTS: TB incidence rate increased from 12.3 (2014) to 14.7 (2017) per 100,000 inhabitants. Morbidity rates also increased in nine out of 15 regions. The proportion of TB cases in specific groups has also increased in the last six years: HIV/AIDS (68%), immigrants (118%), drug users/alcoholics (267%) and homeless people (370%). Several indicators of the national TB program performance have deteriorated including TB case detection, HIV co-infection study and contact tracing activities. Overall results indicate a higher than expected case-fatality ratio (> 3%), high rates of loss from follow-up (> 5%), and low percentage of cohort healing rate (< 90%). This decline is associated with a Control Program with scarce human resources whose central budget decreased by 90% from 2008 to 2014. New molecular diagnostic tools and liquid media culture were only recently implemented. CONCLUSIONS: TB trends and overall program performance indicators have deteriorated in recent years in Chile and several factors appear to be involved. Multiple strategies will be required to rectify this situation.


Assuntos
Tuberculose/epidemiologia , Chile/epidemiologia , Emigrantes e Imigrantes/estatística & dados numéricos , Geografia , Infecções por HIV/epidemiologia , Gastos em Saúde/tendências , Pessoas em Situação de Rua/estatística & dados numéricos , Humanos , Incidência , Fatores de Risco , Fatores Socioeconômicos , Estatísticas não Paramétricas , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Fatores de Tempo , Tuberculose/economia , Tuberculose/etiologia
4.
Afr J AIDS Res ; 18(4): 277-288, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31779568

RESUMO

The past decade has seen a growing emphasis on the production of high-quality costing data to improve the efficiency and cost-effectiveness of global health interventions. The need for such data is especially important for decision making and priority setting across HIV services from prevention and testing to treatment and care. To help address this critical need, the Global Health Cost Consortium was created in 2016, in part to conduct a systematic search and screening of the costing literature for HIV and TB interventions in low- and middle-income countries (LMIC). The purpose of this portion of the remit was to compile, standardise, and make publicly available published cost data (peer-reviewed and gray) for public use. We limit our analysis to a review of the quantity and characteristics of published cost data from HIV interventions in sub-Saharan Africa. First, we document the production of cost data over 25 years, including density over time, geography, publication venue, authorship and type of intervention. Second, we explore key methods and reporting for characteristics including urbanicity, platform type, ownership and scale. Although the volume of HIV costing data has increased substantially on the continent, cost reporting is lacking across several dimensions. We find a dearth of cost estimates from HIV interventions in west Africa, as well as inconsistent reporting of key dimensions of cost including platform type, ownership and urbanicity. Further, we find clear evidence of a need for renewed focus on the consistent reporting of scale by authors of costing and cost-effectiveness analyses.


Assuntos
Infecções por HIV/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , África ao Sul do Saara , Análise Custo-Benefício , Saúde Global/economia , Infecções por HIV/diagnóstico , Infecções por HIV/prevenção & controle , Infecções por HIV/terapia , Serviços de Saúde/economia , Humanos , Tuberculose/diagnóstico , Tuberculose/economia , Tuberculose/prevenção & controle , Tuberculose/terapia
5.
Afr J AIDS Res ; 18(4): 263-276, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31779571

RESUMO

Consistently defined, accurate, and easily accessible cost data are a valuable resource to inform efficiency analyses, budget preparation, and sustainability planning in global health. The Global Health Cost Consortium (GHCC) designed the Unit Cost Study Repository (UCSR) to be a resource for standardised HIV and TB intervention cost data displayed by key characteristics such as intervention type, country, and target population. To develop the UCSR, the GHCC defined a typology of interventions for each disease; aligned interventions according to the standardised principles, methods, and cost and activity categories from the GHCC Reference Case for Estimating the Costs of Global Health Services and Interventions; completed a systematic literature review; conducted extensive data extraction; performed quality assurance; grappled with complex methodological issues such as the proper approach to the inflation and conversion of costs; developed and implemented a study quality rating system; and designed a web-based user interface that flexibly displays large amounts of data in a user-friendly way. Key lessons learned from the extraction process include the importance of assessing the multiple uses of extracted data; the critical role of standardising definitions (particularly units of measurement); using appropriate classifications of interventions and components of costs; the efficiency derived from programming data checks; and the necessity of extraction quality monitoring by senior analysts. For the web interface, lessons were: understanding the target audiences, including consulting them regarding critical characteristics; designing the display of data in "levels"; and incorporating alert and unique trait descriptions to further clarify differences in the data.


Assuntos
Saúde Global/economia , Infecções por HIV/economia , Custos de Cuidados de Saúde/normas , Tuberculose/economia , Coleta de Dados , Infecções por HIV/prevenção & controle , Custos de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde/economia , Humanos , Padrões de Referência , Revisão Sistemática como Assunto , Tuberculose/prevenção & controle , Interface Usuário-Computador
7.
BMC Health Serv Res ; 19(1): 690, 2019 10 12.
Artigo em Inglês | MEDLINE | ID: mdl-31606031

RESUMO

BACKGROUND: In Asia, over 50% of patients with symptoms of tuberculosis (TB) access health care from private providers. These patients are usually not notified to the National TB Control Programs, which contributes to low notification rates in many countries. METHODS: From January 1, 2011 to December 31, 2012, Karachi's Indus Hospital - a private sector partner to the National TB Programme - engaged 80 private family clinics in its catchment area in active case finding using health worker incentives to increase notification of TB disease. The costs incurred were estimated from the perspective of patients, health facility and the program providing TB services. A Markov decision tree model was developed to calculate the cost-effectiveness of the active case finding as compared to case detection through the routine passive TB centers. Pakistan has a large private health sector, which can be mobilized for TB screening using an incentivized active case finding strategy. Currently, TB screening is largely performed in specialist public TB centers through passive case finding. Active and passive case finding strategies are assumed to operate independently from each other. RESULTS: The incentive-based active case finding program costed USD 223 per patient treated. In contrast, the center based non-incentive arm was 23.4% cheaper, costing USD 171 per patient treated. Cost-effectiveness analysis showed that the incentive-based active case finding program was more effective and less expensive per DALY averted when compared to the baseline passive case finding as it averts an additional 0.01966 DALYs and saved 15.74 US$ per patient treated. CONCLUSION: Both screening strategies appear to be cost-effective in an urban Pakistan context. Incentive driven active case findings of TB in the private sector costs less and averts more DALYs per health seeker than passive case finding, when both alternatives are compared to a common baseline situation of no screening.


Assuntos
Setor Privado/economia , Tuberculose/prevenção & controle , Adolescente , Adulto , Análise Custo-Benefício , Árvores de Decisões , Notificação de Doenças/economia , Notificação de Doenças/normas , Diagnóstico Precoce , Feminino , Humanos , Masculino , Programas de Rastreamento/economia , Motivação , Paquistão , Tuberculose/economia , Conduta Expectante/economia , Adulto Jovem
8.
Infect Dis Poverty ; 8(1): 67, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31370909

RESUMO

BACKGROUND: Tuberculosis (TB) is still a major public health problem in China. To scale up TB control, an innovative programme entitled the 'China-Gates Foundation Collaboration on TB Control in China was initiated in 2009. During the second phase of the project, a policy of increased reimbursement rates under the New Cooperative Medical Scheme (NCMS) was implemented. In this paper, we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data. METHODS: In two cross-sectional surveys, quantitative data were collected before (January 2010 to December 2012) and after (April 2014 to June 2015) the intervention in the existing NCMS routine data system. Information on all 313 TB inpatients, among which 117 inpatients in the project was collected. Qualitative data collection included 11 focus group discussions. Three main indicators, non-reimbursable expenses rate (NER), effective reimbursement rate (ERR), and out-of-pocket payment (OOP) as a percentage of per capita household income, were used to measure the impact of intervention by comprising post-intervention data with baseline data. The quantitative data were analysed by descriptive analysis and non-parametric tests (Mann-Whitney U test) using SPSS 22.0, and qualitative data were subjected to thematic framework analysis using Nvivo10. RESULTS: The nominal reimbursement rates for inpatient care were no less than 80% for services within the package. Total inpatient expenses greatly increased, with an average growth rate of 11.3%. For all TB inpatients, the ERR for inpatient care increased from 52 to 66%. Compared with inpatients outside the project, for inpatients covered by the new policy, the ERR was higher (78%), and OOP showed a sharper decline. In addition, their financial burden decreased significantly. CONCLUSIONS: Although the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy, inpatient OOP expenditure was still a major financial problem for patients. Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement. Comprehensive control models are needed to effectively decrease the financial burden on all TB patients.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Tuberculose/economia , China , Estudos Transversais , Declarações Financeiras/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tuberculose/tratamento farmacológico , Tuberculose/prevenção & controle
9.
Trials ; 20(1): 536, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31462284

RESUMO

BACKGROUND: Tuberculosis is one of the greatest global health concerns and disease management is challenging particularly in low- and middle-income countries. Despite improvements in addressing this epidemic in Georgia, tuberculosis remains a significant public health concern due to sub-optimal patient management. Low remuneration for specialists, limited private-sector interest in provision of infectious disease care and incomplete integration in primary care are at the core of this problem. METHODS: This protocol sets out the methods of a two-arm cluster randomized control trial which aims to generate evidence on the effectiveness of a performance-based financing and integrated care intervention on tuberculosis loss to follow-up and treatment adherence. The trial will be implemented in health facilities (clusters) under-performing in tuberculosis management. Eligible and consenting facilities will be randomly assigned to either intervention or control (standard care). Health providers within intervention sites will form a case management team and be trained in the delivery of integrated tuberculosis care; performance-related payments based on monthly records of patients adhering to treatment and quality of care assessments will be disbursed to health providers in these facilities. The primary outcomes include loss to follow-up among adult pulmonary drug-sensitive and drug-resistant tuberculosis patients. Secondary outcomes are adherence to treatment among drug-sensitive and drug-resistant tuberculosis patients and treatment success among drug-sensitive tuberculosis patients. Data on socio-demographic characteristics, tuberculosis diagnosis and treatment regimen will also be collected. The required sample size to detect a 6% reduction in loss to follow-up among drug-sensitive tuberculosis patients and a 20% reduction in loss to follow-up among drug-resistant tuberculosis patients is 948 and 136 patients, respectively. DISCUSSION: The trial contributes to a limited body of rigorous evidence and literature on the effectiveness of supply-side performance-based financing interventions on tuberculosis patient outcomes. Realist and health economic evaluations will be conducted in parallel with the trial, and associated composite findings will serve as a resource for the Georgian and wider regional Ministries of Health in relation to future tuberculosis and wider health policies. The trial and complementing evaluations are part of Results4TB, a multidisciplinary collaboration engaging researchers and Georgian policy and practice stakeholders in the design and evaluation of a context-sensitive tuberculosis management intervention. TRIAL REGISTRATION: ISRCTN, ISRCTN14667607 . Registered on 14 January 2019.


Assuntos
Antituberculosos/uso terapêutico , Administração de Caso/economia , Prestação Integrada de Cuidados de Saúde/economia , Avaliação de Desempenho Profissional/economia , Padrões de Prática Médica/economia , Reembolso de Incentivo/economia , Tuberculose/tratamento farmacológico , Tuberculose/economia , República da Geórgia , Fidelidade a Diretrizes/economia , Humanos , Guias de Prática Clínica como Assunto , Ensaios Clínicos Pragmáticos como Assunto , Fatores de Tempo , Resultado do Tratamento , Tuberculose/diagnóstico , Tuberculose/microbiologia
10.
Artigo em Inglês | MEDLINE | ID: mdl-31336947

RESUMO

Background: Tuberculosis (TB) remains a major social and public health problem in China. The "China-Gates TB Project" started in 2012, and one of its objectives was to reduce the financial burden on TB patients and to improve access to quality TB care. The aims of this study were to determine if the project had positive impacts on improving health service utilization. Methods: The 'China-Gates TB Project' was launched in Yichang City (YC), Hubei Province in April 2014 and ended in March 2015, lasting for one year. A series of questionnaire surveys of 540 patients were conducted in three counties of YC at baseline and final evaluations. Inpatient and outpatient service utilization were assessed before and after the program, with descriptive statistics. Propensity score matching was used to evaluate the impact of the China-Gates TB Project on health service utilization by minimizing the differences in the other characteristics of baseline and final stage groups. Focus group discussions (FGDs) were held to further enrich the results. Results: A total of 530 patients were included in this study. Inpatient rates significantly increased from 33.5% to 75.9% overall (p < 0.001), with the largest increase occurring for low income patients. Outpatient visits increased from 4.6 to 5.6 (p < 0.001), and this increase was also greatest for the poorest patients. Compared with those who lived in developed counties, the overall increase in outpatient visits for illness in the remote Wufeng county was higher. Conclusions: The China-Gates TB Project has effectively improved health service utilization in YC, and poor patients benefited more from it. TB patients in remote underdeveloped counties are more likely to increase the use of outpatient services rather than inpatient services. There is a need to tilt policy towards the poor, and various measures need to be in place in order to ensure health services utilization in undeveloped areas.


Assuntos
Assistência Ambulatorial , Antituberculosos/uso terapêutico , Custos de Cuidados de Saúde , Financiamento da Assistência à Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Pobreza/estatística & dados numéricos , Tuberculose/tratamento farmacológico , Antituberculosos/economia , China , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tuberculose/economia
11.
PLoS One ; 14(7): e0218890, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31265470

RESUMO

BACKGROUND: Truenat is a novel molecular assay that rapidly detects tuberculosis (TB) and rifampicin-resistance. Due to the portability of its battery-powered testing platform, it may be valuable in peripheral healthcare settings in India. METHODS: Using a microsimulation model, we compared four TB diagnostic strategies for HIV-negative adults with presumptive TB: (1) sputum smear microscopy in designated microscopy centers (DMCs) (SSM); (2) Xpert MTB/RIF in DMCs (Xpert); (3) Truenat in DMCs (Truenat DMC); and (4) Truenat for point-of-care testing in primary healthcare facilities (Truenat POC). We projected life expectancy, costs, incremental cost-effectiveness ratios (ICERs), and 5-year budget impact of deploying Truenat POC in India's public sector. We defined a strategy "cost-effective" if its ICER was

Assuntos
Análise Custo-Benefício , Farmacorresistência Bacteriana , Infecções por HIV/diagnóstico , Tuberculose/diagnóstico , Adulto , Feminino , Infecções por HIV/microbiologia , Infecções por HIV/virologia , Custos de Cuidados de Saúde , Humanos , Índia/epidemiologia , Masculino , Microscopia , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/patogenicidade , Sistemas Automatizados de Assistência Junto ao Leito , Setor Público , Rifampina/efeitos adversos , Rifampina/uso terapêutico , Escarro/microbiologia , Tuberculose/tratamento farmacológico , Tuberculose/economia , Tuberculose/microbiologia
12.
Infect Dis Poverty ; 8(1): 44, 2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31182164

RESUMO

BACKGROUND: Tuberculosis (TB) prevalence is closely associated with poverty in China, and poor patients face more barriers to treatment. Using an insurance-based approach, the China-Gates TB program Phase II was implemented between 2012 and 2014 in three cities in China to improve access to TB care and reduce the financial burden on patients, particularly among the poor. This study aims to assess the program effects on service use, and its equity impact across different income groups. METHODS: Data from 788 and 775 patients at baseline and final evaluation were available for analysis respectively. Inpatient and outpatient service utilization, treatment adherence, and patient satisfaction were assessed before and after the program, across different income groups (extreme poverty, moderate poverty and non-poverty), and in various program cities, using descriptive statistics and multi-variate regression models. Key stakeholder interviews were conducted to qualitatively evaluate program implementation and impacts. RESULTS: After program implementation, the hospital admission rate increased more for the extreme poverty group (48.5 to 70.7%) and moderate poverty group (45.0 to 68.1%), compared to the non-poverty group (52.9 to 64.3%). The largest increase in the number of outpatient visits was also for the extreme poverty group (4.6 to 5.7). The proportion of patients with good medication adherence increased by 15 percentage points in the extreme poverty group and by ten percentage points in the other groups. Satisfaction rates were high in all groups. Qualitative feedback from stakeholders also suggested that increased reimbursement rates, easier reimbursement procedures, and allowance improved patients' service utilization. Implementation of case-based payment made service provision more compliant to clinical pathways. CONCLUSION: Patients in extreme or moderate poverty benefited more from the program compared to a non-poverty group, indicating improved equity in TB service access. The pro-poor design of the program provides important lessons to other TB programs in China and other countries to better address TB care for the poor.


Assuntos
Assistência à Saúde/economia , Acesso aos Serviços de Saúde/economia , Aceitação pelo Paciente de Cuidados de Saúde , Satisfação do Paciente , Tuberculose/economia , Tuberculose/psicologia , Adulto , Idoso , Antituberculosos/economia , Antituberculosos/uso terapêutico , China , Estudos Transversais , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde , Modelos Logísticos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Satisfação do Paciente/economia , Pobreza/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários , Tuberculose/tratamento farmacológico
13.
Glob Health Sci Pract ; 7(2): 258-272, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31249022

RESUMO

INTRODUCTION: In the era of declining development assistance for health, transitioning externally funded programs to governments becomes a priority for donors. However, the process requires a careful approach not only to preserve the public health gains that have already been achieved but also to expand on them. In the Eastern Europe and Central Asia region, countries are expected to graduate from support from the Global Fund to Fight AIDS, Tuberculosis and Malaria in or before 2025. We aim to describe transition risks and identify possible means to address them. METHODS: Using a theory-based conceptual framework-Transition Preparedness Assessment of Tuberculosis and HIV/AIDS programs-we investigated transition-related challenges through a health systems lens in 10 countries of the Eastern Europe and Central Asia region during 2015-2017. Study findings were derived from systematic collection of quantitative data on socioeconomic indicators and disease epidemics as well as qualitative data from in-depth interviews with 264 stakeholders. These findings were then compared with other donor transition experiences documented elsewhere. RESULTS: We found numerous common transition challenges, such as poor monitoring of a country's macroeconomic performance along with weakness in estimating financial needs for successful transition; limited political will of governments to replace donor-funded programs; punitive legislation criminalizing certain behaviors and constraining the government's ability to allocate funds and contract civil society organizations essential to providing services for key populations; limited coordination function of governments and weak decision-making power of coordinating mechanisms obscuring the latter's future role; and inadequate function of national procurement and supply chain management systems undermining an uninterrupted supply of quality-assured drugs and commodities. These challenges are compounded by the risks related to health workforce management leading to specialist shortages and/or inadequately skilled and qualified professionals and by limited funding for critical surveillance activities. CONCLUSION: The complex and multidimensional transition process requires a multipronged approach through well-planned collective and coordinated responses from global, bilateral, and national partners in coming years. Other similar transition processes may provide guidance. Although no "one-size-fits-all" approach exists, previous experiences highlight a need for both early planning and monitoring of the transition along several key dimensions. Issues that could threaten the maintenance of health gains include ongoing stigma against key populations; continued heavy reliance on external funding in some countries, especially for preventive services; the institutional viability of the country coordinating mechanisms; and emerging difficulties with procurement of quality drugs at reasonable prices.


Assuntos
Assistência à Saúde/economia , Administração Financeira , Governo , Infecções por HIV/terapia , Financiamento da Assistência à Saúde , Cooperação Internacional , Tuberculose/terapia , Ásia , Europa Oriental , Saúde Global , Infecções por HIV/economia , Humanos , Malária/economia , Malária/terapia , Inquéritos e Questionários , Tuberculose/economia
14.
PLoS One ; 14(6): e0214928, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31166942

RESUMO

BACKGROUND: Private providers dominate health care in India and provide most tuberculosis (TB) care. Yet efforts to engage private providers were viewed as unsustainably expensive. Three private provider engagement pilots were implemented in Patna, Mumbai and Mehsana in 2014 based on the recommendations in the National Strategic Plan for TB Control, 2012-17. These pilots sought to improve diagnosis and treatment of TB and increase case notifications by offering free drugs and diagnostics for patients who sought care among private providers, and monetary incentives for providers in one of the pilots. As these pilots demonstrated much higher levels of effectiveness than previously documented, we sought to understand program implementation costs and predict costs for their national scale-up. METHODS AND FINDINGS: We developed a common cost structure across these three pilots comprising fixed and variable cost components. We conducted a retrospective, activity-based costing analysis using programmatic data and qualitative interviews with the respective program managers. We estimated the average recurring costs per TB case at different levels of program scale for the three pilots. We used these cost estimates to calculate the budget required for a national scale up of such pilots. The average cost per privately-notified TB case for Patna, Mumbai and Mehsana was estimated to be US$95, US$110 and US$50, respectively, in May 2016 when these pilots were estimated to cover 50%, 36% and 100% of the total private TB patients, respectively. For Patna and Mumbai pilots, the average cost per case at full scale, i.e. 100% coverage of private TB patients, was projected to be US$91 and US$101, respectively. In comparison, the national TB program's budget for 2015 averages out to $150 per notified TB case. The total annual additional budget for a national scale up of these pilots was estimated to be US$267 million. CONCLUSIONS: As India seeks to eliminate TB, extensive national engagement of private providers will be required. The cost per privately-notified TB case from these pilots is comparable to that already being spent by the public sector and to the projected cost per privately-notified TB case required to achieve national scale-up of these pilots. With additional funds expected to execute against national TB elimination commitments, the scale-up costs of these operationally viable and effective private provider engagement pilots are likely to be financially viable.


Assuntos
Setor Privado/economia , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológico , Análise Custo-Benefício , Gerenciamento Clínico , Humanos , Índia , Projetos Piloto , Avaliação de Programas e Projetos de Saúde , Setor Público , Estudos Retrospectivos , Tuberculose/economia
16.
Afr J AIDS Res ; 18(2): 95-103, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31043120

RESUMO

This paper examines the institutional management of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) in Botswana. We analyse the often contested roles of the state and non-governmental organisations (NGOs) as recipients of GFATM and partners in extending public health service provision to communities. Of importance is that Botswana's first GFATM grant had to be administratively closed, and the country was not awarded any other grant (especially for HIV/AIDS) until over a decade later. Following this, it is of interest to understand the ways in which institutions manage grant programmes. This article concludes that the "big brother" relationship of the state in relation to NGOs is crippling the critical and constructive effects of these organisations to deliver needed community-based health services in Botswana. GFTAM represents a window of opportunity for creating an effective civil society whose local activities will not be seen as being led covertly by the state. This article contributes to both theory and practice within the scholarship of development aid in Africa. Qualitative research methods were used, including in-depth interviews with public sector policy makers, all GFATM principal and sub-recipients, members of the Country Coordinating Mechanism (CCM) and NGOs.


Assuntos
Síndrome de Imunodeficiência Adquirida/economia , Assistência à Saúde/economia , Assistência à Saúde/organização & administração , Malária/economia , Tuberculose/economia , Síndrome de Imunodeficiência Adquirida/prevenção & controle , Botsuana , Assistência à Saúde/tendências , Organização do Financiamento , Humanos , Malária/prevenção & controle , Organizações , Pesquisa Qualitativa , Tuberculose/prevenção & controle
17.
PLoS Med ; 16(4): e1002788, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-31039158

RESUMO

BACKGROUND: Tuberculosis (TB) still represents a major public health problem in Latin America, with low success and high default rates. Poor adherence represents a major threat for TB control and promotes emergence of drug-resistant TB. Expanding social protection programs could have a substantial effect on the global burden of TB; however, there is little evidence to evaluate the outcomes of socioeconomic support interventions. This study evaluated the effect of a conditional cash transfer (CCT) policy on treatment success and default rates in a prospective cohort of socioeconomically disadvantaged patients. METHODS AND FINDINGS: Data were collected on adult patients with first diagnosis of pulmonary TB starting treatment in public healthcare facilities (HCFs) from 16 health departments with high TB burden in Buenos Aires who were followed until treatment completion or abandonment. The main exposure of interest was the registration to receive the CCT. Other covariates, such as sociodemographic and clinical variables and HCFs' characteristics usually associated with treatment adherence and outcomes, were also considered in the analysis. We used hierarchical models, propensity score (PS) matching, and inverse probability weighting (IPW) to estimate treatment effects, adjusting for individual and health system confounders. Of 941 patients with known CCT status, 377 registered for the program showed significantly higher success rates (82% versus 69%) and lower default rates (11% versus 20%). After controlling for individual and system characteristics and modality of treatment, odds ratio (OR) for success was 2.9 (95% CI 2, 4.3, P < 0.001) and default was 0.36 (95% CI 0.23, 0.57, P < 0.001). As this is an observational study evaluating an intervention not randomly assigned, there might be some unmeasured residual confounding. Although it is possible that a small number of patients was not registered into the program because they were deemed not eligible, the majority of patients fulfilled the requirements and were not registered because of different reasons. Since the information on the CCT was collected at the end of the study, we do not know the exact timing for when each patient was registered for the program. CONCLUSIONS: The CCT appears to be a valuable health policy intervention to improve TB treatment outcomes. Incorporating these interventions as established policies may have a considerable effect on the control of TB in similar high-burden areas.


Assuntos
Antituberculosos/uso terapêutico , Política de Saúde , Política Pública , Tuberculose/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antituberculosos/economia , Argentina/epidemiologia , Estudos de Coortes , Feminino , Implementação de Plano de Saúde/economia , Implementação de Plano de Saúde/normas , Implementação de Plano de Saúde/estatística & dados numéricos , Política de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistemas de Apoio Psicossocial , Política Pública/economia , Remuneração , Fatores Socioeconômicos , Resultado do Tratamento , Tuberculose/economia , Tuberculose/epidemiologia , Populações Vulneráveis/estatística & dados numéricos , Adulto Jovem
18.
PLoS One ; 14(5): e0217055, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31095637

RESUMO

The perspectives of social selection and causation have long been debated. Social selection theory is as "social" as social causation theory, since all diseases are social and no biological process occurs outside society. To identify the social selection pathway and historical juncture affected by socioeconomic and political changes, we investigated the reciprocal impact of suffering from tuberculosis (TB) on the current socioeconomic position (SEP), stratified by childhood SEP. We also examined the extent to which the social consequences of ill health changed since the East Asian economic downturn. Data were collected for 2007-2012 from the Korea National Health and Nutritional Examination Survey. To identify associations between TB history and current household income (HHI), we constructed an ordinal logistic regression model adjusted for covariates, including age, gender, educational attainment, and job status. We adopted a recursive regression model to examine trend changes in this association from 1980-2012 to 2003-2012. Of 28,136 participants, 936 had experienced TB. In the first ordinal logistic regression, the TB group was more likely to have lower HHI than the non-TB group. The odds ratios (ORs) increased from 1.30 (1980-2012) to 1.86 (2003-2012) for the TB group, increasing their probability of having low HHI. Among the low childhood SEP group, the TB group's probability of having low HHI was 1.35 (95% confidence interval [CI]: 1.16-1.57) during 1980-2012, which increased to 2.01 (95% CI: 1.37-2.95) during 2003-2012. For the high childhood SEP group, the TB group's OR range fluctuated, similar to that for the non-TB group. The results support the social selection pathway from TB history to adverse impact on current SEP. Our study identified downward social mobility due to TB history among the low childhood SEP group. Moreover, negative social consequences deteriorated since the East Asian economic crisis.


Assuntos
Efeitos Psicossociais da Doença , Classe Social , Tuberculose/economia , Tuberculose/epidemiologia , Adulto , Idoso , Controle de Doenças Transmissíveis , Economia , Escolaridade , Emprego/estatística & dados numéricos , Feminino , Inquéritos Epidemiológicos , História do Século XX , História do Século XXI , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Probabilidade , Análise de Regressão , República da Coreia/epidemiologia , Fatores Socioeconômicos , Tuberculose/história
19.
BMC Health Serv Res ; 19(1): 213, 2019 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-30943967

RESUMO

BACKGROUND: The frequent occurrence of medicine stockouts represents a significant obstacle to tuberculosis control in South Africa. Stockouts can lead to treatment alterations or interruptions, which can impact treatment outcomes. This study investigates the determinants and effects of TB drug stockouts and whether poorer districts are disproportionately affected. METHODS: TB stockout data, health system indicators and TB treatment outcomes at the district level were extracted from the District Health Barometer for the years 2011, 2012 and 2013. Poverty terciles were constructed using the Census 2011 data to investigate whether stockouts and poor treatment outcomes were more prevalent in more impoverished districts. Fixed-effects regressions were used to estimate the effects of TB stockouts on TB treatment outcomes. RESULTS: TB stockouts occurred in all provinces but varied across provinces and years. Regression analysis showed a significant association between district per capita income and stockouts: a 10% rise in income was associated with an 8.50% decline in stockout proportions. In terms of consequences, after controlling for unobserved time invariant heterogeneity between districts, a 10% rise in TB drug stockouts was found to lower the cure rate by 2.10% (p < 0.01) and the success rate by 1.42% (p < 0.01). These effects were found to be larger in poorer districts. CONCLUSIONS: The unequal spread of TB drug stockouts adds to the socioeconomic inequality in TB outcomes. Not only are stockouts more prevalent in poorer parts of South Africa, they also have a more severe impact on TB treatment outcomes in poorer districts. This suggests that efforts to cut back TB drug stockouts would not only improve TB treatment outcomes on average, they are also likely to improve equity because a disproportionate share of this burden is currently borne by the poorer districts.


Assuntos
Antituberculosos/provisão & distribução , Tuberculose/tratamento farmacológico , Antituberculosos/economia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Renda , Pobreza , Áreas de Pobreza , Fatores Socioeconômicos , África do Sul/epidemiologia , Resultado do Tratamento , Tuberculose/economia , Tuberculose/epidemiologia
20.
PLoS One ; 14(4): e0214492, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30943223

RESUMO

BACKGROUND: In South Africa, 600-700 new cases of paediatric cancers have been reported every year for the past 25 years, and in the year 2000, HIV/AIDS was responsible for 42,479 deaths in children under five. These children need intermediate care but research in the field is lacking, with the few costing studies conducted in South Africa reporting a range of inpatient day costs. METHODS: A retrospective cost analysis for the period April 2014-March 2015 was undertaken from the provider perspective in the public sector, using a step down costing approach. Costs of paediatric intermediate care were estimated for an intermediate care facility (ICF) and a tertiary hospital in Cape Town. Costs were inflated to 2016 prices and reported in US dollars. RESULTS: Cost per inpatient day was $713.09 at the hospital and $695.17 at the ICF for any child requiring care at these institutions. The cost for a paediatric patient who is HIV/TB co-infected was $7 130.94 and $6 951.67 at the hospital and ICF respectively, assuming an average length of stay of 10 days. For a patient with terminal brain carcinoma the cost was $19 966.63 and $19 464.69 at the hospital and ICF respectively, assuming an average length of stay of 28 days. Personnel costs accounted for 60% and 17% of the total cost at the hospital and ICF respectively. Overhead costs accounted for 12.33% at the ICF and 4.48% at the hospital. CONCLUSIONS: The drivers of cost are not uniform across settings. Providing intermediate care at an ICF could be less costly than providing this care at a hospital, however more in-depth analysis is needed. The costs presented in this study were considerably higher than those found in other studies, however, the paucity of cost data available in this area makes comparisons difficult.


Assuntos
Custos de Cuidados de Saúde , Instituições para Cuidados Intermediários/economia , Pediatria/economia , Centros de Atenção Terciária/economia , Criança , Análise Custo-Benefício , Infecções por HIV/economia , Infecções por HIV/terapia , Humanos , Pacientes Internados , Neoplasias/economia , Neoplasias/terapia , Setor Público , Estudos Retrospectivos , África do Sul , Tuberculose/economia , Tuberculose/terapia
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