Access to tuberculosis care in rural China : : Comparing the impact of alternative control projects

Abstract: Background: China has the second highest burden of tuberculosis (TB) worldwide. The modern TB control strategies Directly Observed Treatment, Short Course (DOTS) has, since 1992, been adopted by the National TB Control Programme (NTP) with subsidized or free TB care to smear-positive TB patients. After one decade of implementation, the NTP-DOTS project now covers more than 90% of Chinese population, however, the case detection rate of smear-positive TB in China was only 33% based on the 4th national TB survey, far below the WHO target of 70%. Prompt and adequate access to and utilization of TB care are critical to TB case detection and effective anti-TB control. Objective: To gain in-depth understanding of the perceptions and experiences of access to TB care among TB patients, health-care providers and TB management staff, to describe and compare health seeking behaviours, diagnostic delays and patients expenditures for TB care in new TB patients and patients with longer than two weeks cough; further, to study the equity in access to and utilization of TB care with respect to age, gender, medical insurance, income, education, occupation, disease profiles and the availability of NTP-DOTS project in rural China. Methods: The study was set in two counties in Jiangsu Province, one NTP-DOTS project covered county - Jianhu where subsidized TB care was available in the county TB dispensary, and a non-DOTS county - Funing, where TB care was available both in general hospitals and the TB dispensary financed with out-of-pocket payment. Four sub-studies were implemented (Papers I-IV). Focus group discussion was organized with patients and health-care providers to gain an in-depth understanding of the perceptions and experiences related to access to TB care (Paper I); two cohort studies with 493 new TB patients (paper II and III) and one cross-sectional study with 1204 cough patients (paper IV) were carried out to study the access to and utilization of TB care measured by diagnostic delay, expenditures for TB care and health seeking experiences of patients. Main findings: Participants of the focus group discussion reported that patients who were poor, female, and/or elderly were more reluctant to seek health care and/or tended to seek care at village health stations for cough because of financial difficulties. The mean of diagnostic delay for TB patients was 58 days in Jianhu County and 40 days in Funing County (p<0.01), which was due mainly to the longer provider s (47 vs. 32 days) or doctor s delay in Jianhu (31 vs. 10 days). In Funing, patients at the lowest income quartile had 63% probability of a shorter patient s delay compared to those at highest income group, and poor farmer patients had both longer patient s and doctor s delays in Funing. Less educated patients had a longer patient s delay, and uninsured patients experienced a longer doctor s delay in Jianhu. No significant differences in patient s delay were found in cough patients between the two counties (35 vs. 29 days, p>0.05). Forty percent cough patients in Jianhu and 78 % in Funing chose non-hospitals for their first care seeking. Poor patients and patients with lower education had higher probability to visit a non-hospital first. Less than 2% of TB patients directly visited the county TB dispensary. The economic burden of TB care was heavy in both counties. Patients expenditure for TB care before getting a TB diagnosis was 715CNY (Chinese Yuan) in Jianhu, much higher than the 256CNY in Funing (p<0.0001), while it was significantly lower in Jianhu than in Funing after TB diagnosis (157 vs. 835CNY, p<0.0001). Conclusion: Poor socioeconomic status is still the main barrier in access to and utilisation of TB care. The poor TB patients are benefited by the pro-poor NTP-DOTS projects after they get the TB diagnosis under the project, but they suffer a heavy economic burden before they enter the NTP-DOTS project. The total patients expenditure was not reduced substantially in the project county, but shifted from after diagnosis to before diagnosis, which implies delays in diagnosis and treatment. Findings from this study indicate that the pro-poor effects of a vertical TB control project will be reduced when a project is embedded in a market-oriented health system based on fee-for-service revenue, where provider incentives work contrary to patients interests.