Barriers to tuberculosis diagnosis and treatment in Zambia
Dale Needham
2005-03-16
Someone with untreated tuberculosis (TB) will infect up to 14 others over a year.
TB programmes must lower barriers to care-seeking to reduce this spread. From
patients perspectives, barriers include treatment costs and travel. Proposed
reforms to TB programmes in sub-Saharan Africa, including decentralization, must
consider each country's context to prevent negative impacts on care-seeking and
under-funded primary health care services. TB
treatment is a very cost-effective health intervention in the developing world.
Despite this, the disease kills almost two million adults each year. Many
patients can spot the symptoms of TB and see the need for treatment, but
socio-economic and cultural factors may prevent effective disease control.
In this study at the University of Zambia, interviews were conducted with 202
patients in 1996. These interviews revealed three themes underlying patient
barriers to TB diagnosis:
- number of health care encounters and duration of illness prior to
diagnosis
- financial constraints and unrecognized patient costs
- travel distances.
On average, patients have 6.7 health encounters over 63 days before being
referred for TB diagnosis at the centralized government Chest Clinic. This
period can involve self-treatment with western or herbal remedies, or
visits to traditional healers or private physicians. Even within the public
sector, patients need to buy government-sponsored health insurance or pay a fee
to receive a referral to the free Chest Clinic. Confusion over how the
referral system works is another important barrier. There
are unrecognized costs of seeking care, such as special food and lost
income. In addition, patients travelling to seek care spend 16 percent of their
monthly income on transport. Others simply cannot get care if they are too ill
to walk. Patients are often tempted to travel if they think that a more distant
facility provides a better service or a more reliable drug supply.
These results have implications for the impact of reforms proposed for TB
programmes in sub-Saharan Africa, particularly decentralization. Under decentralization,
TB diagnosis occurs at neighbourhood clinics. This reduces the number of health
encounters and travel distances involved. It may also cut congestion at larger
hospitals with an opportunity to improve quality of care there. However, the
extra burden of TB care may overstretch under-funded primary health services.
No single ideal decentralized
design for TB treatment exits each country must consider its own resources
in the decision-making process. Two critical success factors are a minimum level
of financial resources and infrastructure and parallel reform throughout the
entire public sector. For successful decentralization, the researchers
recommend:
- accessing extra donor and private funding
- cutting costs by downsizing specialist hospital care
- reassessing the system of health referral
- providing education and financial or other incentives to all health care
providers to refer patients to the TB programme
- redesigning TB clinic logistics to be more patient-friendly
- providing communication skills training for TB clinic staff.
Another proposed reform is the integration of TB programmes with other health
services. TB programmes could offer access to free anti-TB drugs via private
practitioners. They could also utilize the convenient location and familiarity
of traditional healers. This potential reform will need ongoing education of
private practitioners. Further integration of TB and HIV programmes may also be
critical to reducing patient barriers to care-seeking. This could involve:
- community and volunteer involvement
- local income generation projects
- evaluation of cost savings from integration
- specific donor funding.
In much of sub-Saharan Africa, poorly resourced primary health care services
are already under severe pressure. Any reform of TB programmes must be based
upon a strengthening of the infrastructure and funding for local health care
services to ensure that policies, such as decentralization, do not harm
care-seeking and the running of facilities.
Related Source(s):
Patient care seeking barriers and tuberculosis programme reform: a
qualitative study, Health Policy 67: 93-106, by D. Needham, D. Bowman, S.
Foster and P. Godfrey-Faussett, 2004
HINARI subscribers can access the full-text article here. More
information.
(Source: id21 Research
highlight, January 11, 2005)
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