Author: clarinet

ADDRESSING POVERTY
IN TB CONTROL

TB and Poverty Sub-Group

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Addressing Poverty in TB Control

ADDRESSING POVERTY
IN TB CONTROL

	Steps involved	Factors/categories to consider	Actions to consider
	Identification of the / poor and vulnerable / groups in the / country/region / served by the / national TB control / programme	Groups and situations including: / unemployed / homeless people / gender-related discrimination / marginalized ethnic groups / people in remote locations / urban poor / special groups (see Chapter 4)	Establish the profile of poor and vulnerable groups in the country/region using: / government (or other) data on the prevalence and distribution of poverty and social vulnerability and on poverty-reduction plans / information on which types of health care providers are used by poor and vulnerable groups / locally conducted surveys on the socio-economic status of TB patients and poverty related disparities / information on any adaptations already made in DOTS delivery to serve poor and vulnerable groups in the country
	Identification of the / barriers to accessing / TB services faced / by the poor and / vulnerable groups in / the country/region	Economic barriers: / complexity of pathway to access care / costs of care-seeking / Geographical barriers: / distance from TB services / Social and cultural barriers: / stigma / fear of losing work / lack of knowledge of TB and services / gender-related factors / lack of health system responsiveness / Health system barriers: / staff attitudes to poor patients / lack of effective peripheral services	Assess economic barriers by examining: / whether the organization of the TB services simplifies the health care pathway; whether diagnostic and treatment services for TB are well integrated in general primary care facilities; / whether treatment observation requires patients to make multiple visits; / which services provided by the national TB control programme patients are required to pay for / Assess geographical barriers by identifying areas where patients have to travel long distances or over difficult terrain to reach TB services / Assess social and cultural barriers by: / Identifying areas and population groups in which TB services are underutilized; / identifying and analysing the principal barriers to accessing TB services which affect poor and vulnerable groups / Assess health system barriers by: / investigating staff attitudes towards poor patients; / assessing whether decentralization leads to strengthening of TB services at primary care level
	Identification of / potential actions / to overcome the / barriers to access	Adapting the national TB control programme plan to address the needs of poor and vulnerable groups, including specific measures to address economic, geographical, social/cultural and health system barriers. / Deciding country-specific priorities for pro-poor interventions, taking account of needs, resources, feasibility, and effectiveness of the measures envisaged	Address economic barriers by: / integrating TB services within primary care provision; encouraging pro-poor PPM DOTS; promoting TB control in workplaces; improving the coverage of smear microscopy networks; avoiding user-fees; provision of free smear microscopy and treatment; providing food; arranging social security / Address geographical barriers by: / extending diagnostic and treatment services to remote regions; bringing poor patients from remote areas to TB services; providing free transport; developing appropriate community-based TB care models / Address social and cultural barriers by: / engaging former TB patients and TB support groups to advocate for TB services and encourage community mobilization; ensuring that health staff attitudes and behaviour do not reinforce stigma; advocating for legal frameworks to protect against loss of employment because of TB; ensuring that the TB health promotion plan takes account of the specific needs of poor and vulnerable groups; ensuring that gender-related needs are addressed in TB control activities; providing psychological support in the community; considering cooperation with traditional health providers / Address health system barriers by: / adapting health care facility schedules; developing communication skills among health care staff and discouraging discrimination against poor patients; using total quality management to ensure that services remain responsive to the needs of the poor; encouraging community mobilization and demand for TB services among the poor; engaging in health service decentralization to ensure capacity strengthening in less well served areas and TB control as a district-level priority

Practical steps to address poverty in TB control

Chapter 1

Chapter 2

Chapter 3

Addressing Poverty in TB Control

	Situations and / population groups / requiring special / consideration	Migrant populations: / refugee communities, asylum seekers, economic migrants and displaced populations, cross-border populations Pockets of deprivation in wealthier countries: / ethnic minorities, homeless people, injecting drug users, prison populations, any other deprived population groups in the country	Define the special situations and vulnerable groups in the country/region / Identify these groups and their locations / Assess the problems they face in accessing TB services / Establish priorities for action based on needs, feasibility, available resources, and effectiveness of the interventions / Examine current services available to the priority groups and identify current health care providers / Define strategies and measures to improve access to TB services by the poor and vulnerable groups / Build partnerships with current providers of services for the vulnerable groups / Plan a phased implementation of the measures selected
	Harnessing / resources for / pro-poor / TB services	Available strategies to engage in broad initiatives to improve access to health services / Sources of funding for improvement of health outcomes / Institutions offering additional financial and other resources / Human resources to expand the public and private sector involvement in TB services / Technologies to enhance efficiency and effectiveness of TB services	Identify any new partnerships, financing mechanisms, human resources and tools or technologies that might be available / Assess the feasibility of mobilizing and maintaining these resources / Prioritize which existing mechanisms might offer the greatest benefits in the short and medium term / Identify new resources to target for mobilization within the next six months, and within the next two years / Identify the three most influential external and local stakeholders who could help to address priority needs
	Assessment of the / pro-poor performance / of the national TB / control programme / and the impact of / pro-poor measures	Targets for TB control in the poor / Distribution of TB in the population / Beneficiaries of DOTS services / Poverty-related disparities / Assessment of impact of pro-poor measures	Facilitate monitoring of poverty-related inequalities and the impact of pro-poor / interventions by: / Harnessing the human and other resources required for equity monitoring through alliances with partners / Considering the inclusion of socio-economic variables in routine data collection and analysis; / Ensuring that TB-related questions are included in DHS, LSMS and other household surveys / Ensuring that socio-economic questions are included in TB prevalence surveys / Conducting periodic studies of care-seeking, diagnostic delay and use of DOTS in health facilities, with linked socioeconomic data / Conducting qualitative assessments among community members and TB patients about who benefits from TB services and who does not

Options for National TB Control Programmes

Chapter 4

Chapter 5

Chapter 6

Addressing TB and Poverty
The links between TB and poverty

The association between poverty and TB is well established. TB infection is transmitted more readily in the environmental conditions of poverty: overcrowding, inadequate ventilation and malnutrition. Improvements in socioeconomic conditions will therefore lead to reductions in tuberculosis incidence. They should also lead to improvements in access to care, its rational use, and quality of care.
Booming population expansion, combined with poor civic planning and lack of resources for infrastructure development, has resulted in sprawling slum settlements in many urban areas, especially in the poorest countries. About 1 billion people live in urban slums and in the next 30 years the number is expected to reach 2 billion. In the poorest countries, about 80% of the urban population live in slums. The poor socioeconomic and environmental conditions that characterize slums facilitate transmission of most communicable diseases, including TB. The burden of TB is often greater in urban than in rural settings.
Urban areas themselves pose distinct challenges to effective TB control: challenges related to the multiplicity of public and private health-care providers, to the complex mix of often poorly coordinated health authorities, and to the variety of patient populations with diverse characteristics and needs – slum-dwellers, migrants, drug addicts, homeless people, prison inmates and those with TB-HIV co-infection.
In recent years, there has been a growing recognition that TB itself reduces people’s ability to work and earn a living, and that TB control therefore has the potential to reduce poverty. There is a need for a better understanding of this issue. The Partnership has recently commissioned a study by the World Bank of the economic impacts of TB at the household and macro level in Africa.

Concurrently there is increasing recognition that poverty means far more than economic poverty alone. It encompasses lack of opportunities (including capabilities), lack of voice and representation, and vulnerability to shocks. The Stop TB Partnership has adopted this broad conceptualization of poverty.
In 2003 the Stop TB Partnership commissioned an in-depth analysis of the evidence that TB control reduces poverty. The analysis was positive at the global level in that:
the DOTS strategy’s standardized, public health approach to TB treatment, by providing subsidized quality TB care, promotes better access to the poor than privately financed TB care;
the emphasis on DOTS implementation in developing countries promotes equity in service provision at the global level.
However, at the national level and below:
Even where DOTS programmes are well established, patients with TB face substantial costs prior to TB diagnosis because care-seeking pathways are long and involve many consultations with different providers. While aggregate costs for poor people tend to be lower than those for non-poor people, costs as a proportion of income are much higher for the poor.
Poor TB patients in developing countries are mainly dependent on daily wages or income from petty trading and have no security of income or employment. In many studies, patients were found to have borrowed money, used transfer payments (given by friends or relatives), or sold assets on account of their illness.
There are often instances where TB patients from poorer sections of society are missed or excluded from DOTS services.

In 2005 the TB and Poverty Subgroup of the DOTS Expansion Working Group, together with the Network for Action on TB and Poverty and the WHO Stop TB Department, published a document, Addressing poverty in TB control (http://www.who.int/tb/challenges/poverty/en/) , which outlines options for national TB programme managers to choose from in addressing poverty issues in DOTS implementation. This guide is intended to be used to prioritize the needs of the poor and vulnerable in implementing all the activities of the Global Plan (www.stoptb.org/globalplan). As evidence and experience accumulate, these options will be revised and reformulated into formal guidelines for use at national and international levels.
Poor and vulnerable TB patients will benefit from tangible improvements as policy-makers and service providers promote this cycle of action by following the six steps laid out in the document. These practical steps are supported by the Partnership’s working groups as set out in their individual strategic plans for 2006–2015 and by the international TB Research community (http://www.who.int/tdr/publications/publications/swg_tub.htm). Both in overall vision and in country-level specific action, the implementation of this plan will make a substantial contribution towards achieving the MDGs for communicable diseases and poverty reduction.
The six steps laid out in the document are also shown in the tables on the middle pages of this brochure, for ease of reference. Further detail may be found in the chapters of the guide as noted in these tables.