Patient's site of first access to health system influences length of delay for tuberculosis treatment in Tajikistan

BACKGROUND: Tajikistan has the highest incidence rate of tuberculosis (TB) in Central Asia. Its health system still bears many features from Soviet times and is under-funded. Affordability is a major barrier to health care. Little is known about health care seeking of TB patients in post-Soviet countries and their delay until the start of TB therapy. The low estimated case detection rate in Tajikistan suggests major problems with access to care and consequently long delays are likely. METHODS: The study investigated extent and determinants of patient and health system delays for TB. A questionnaire was administered to a cohort of TB patients in twelve study districts representing a wide range of conditions found in Tajikistan. Common patterns of health care seeking were analysed. Cox proportional hazards models using eight predictor variables, including characteristics of health services delivery, were built to identify determinants of patient and health system delays. RESULTS: Two-hundred-and-four TB patients were interviewed. A common pattern in treatment-seeking was visiting a specialised TB facility at some stage. Typical delays until start of TB therapy were moderate and did not confirm the expectation of long delays. Median patient, health system and total delays to TB treatment were 21.5, 16 and 52 days, respectively. None of the investigated predictors was significantly associated with patient delay. The type of facility, where patients made their first contact with the health system, was the main determinant of health system delay (p > 0.00005). We show for the first time that patients who had fallen ill and first presented to health care in Russia had the longest delays. Those who first presented to peripheral primary care facilities also had relatively long delays. CONCLUSIONS: While overall delays were moderate, further improvement is needed for different subgroups. An international referral system between Russia and Tajikistan to reduce delays of Tajik migrants who develop active TB in Russia is urgently needed and would benefit both countries. Within Tajikistan, diagnostic pathways for patients in the periphery should be shortened. To achieve this, strengthening of sputum smear examination possibly including collection of sputa at peripheral primary care facilities may be needed

Acrocephalus orinus: A Case of Mistaken Identity

Recent discovery of the Large-billed Reed Warbler (Acrocephalus orinus) in museums and in the wild significantly expanded our knowledge of its morphological traits and genetic variability, and revealed new data on geographical distribution of the breeding grounds, migration routes and wintering locations of this species. It is now certain that A. orinus is breeding in Central Asia; however, the precise area of distribution remains unclear. The difficulty in the further study of this species lies in the small number of known specimens, with only 13 currently available in museums, and in the relative uncertainty of the breeding area and habitat of this species. Following morphological and genetic analyses from Svensson, et al, we describe 14 new A. orinus specimens from collections of Zoological Museums of the former USSR from the territory of Central Asian states. All of these specimens were erroneously labeled as Blyth's Reed Warbler (A. dumetorum), which is thought to be a breeding species in these areas. The 14 new A. orinus specimens were collected during breeding season while most of the 85 A. dumetorum specimens from the same area were collected during the migration period. Our data indicate that the Central Asian territory previously attributed as breeding grounds of A. dumetorum is likely to constitute the breeding territory of A. orinus. This rare case of a re-description of the breeding territory of a lost species emphasizes the importance of maintenance of museum collections around the world. If the present data on the breeding grounds of A. orinus are confirmed with field observations and collections, the literature on the biology of A. dumetorum from the southern part of its range may have to be reconsidered

Factors determining household expenditure for tuberculosis and coping strategies in Tajikistan

Objective: To investigate factors influencing expenditure levels and the use of potentially detrimental coping strategies among tuberculosis (TB) patients. For the purpose of the present study, potentially detrimental coping strategies included borrowing money and selling assets. Method: Questionnaire survey with an initial and a follow-up interview of each adult new pulmonary TB case registered over a period of 4 months, conducted in 12 districts with DOTS in Tajikistan, one of the poorest countries in the world. Results: Patients and their households faced mean expenditures of US$396 related to a TB episode. In multivariate mixed-effect regression models, the main determinants of out-of-pocket payments-either over the whole course of the disease or after enrolment in DOTS treatment-were 'complimentary treatment' besides the anti-TB drugs, duration of hospitalization and treatment delay. Complimentary treatment mainly consisted of vitamins and rehydrating infusions. Sex showed no association with expenditure. To cope with the costs of illness, two-thirds of patients employed a potentially detrimental coping strategy. TB patients raised on average US$ 23 through loans with interest, US$57 through loans without interest and US$ 102 through selling assets. Conclusion: The catastrophic out-of-pocket payments faced by TB patients are correlated with receiving complimentary treatment, delay to treatment and duration of hospitalisation. The widespread use of potentially detrimental coping strategies illustrates that TB constitutes a substantial risk of impoverishment. More parsimonious use of complimentary treatment and hospitalisation could reduce illness-related costs for patients and should be carefully considere

Out-of-pocket expenditures for primary health care in Tajikistan : a time-trend analysis

BACKGROUND: Aligned with the international call for universal coverage of affordable and quality health care, the government of Tajikistan is undertaking reforms of its health system aiming amongst others at reducing the out-of-pocket expenditures (OPE) of patients seeking care. Household surveys were conducted in 2005, 2007, 2008 and 2011 to explore the scale and determinants of OPE of users in four district of Tajikistan, where health care is legally free of charge at the primary level. METHODS: Using the data from four cross-sectional household surveys conducted between 2005 and 2011, time trends in OPE for consultation fees, drugs and transport costs of adult users of family medicine services were analysed. To investigate differences along the economic status, an asset index was constructed using principal component analysis. RESULTS: Adjusted for inflation, OPE for primary care have substantially increased in the period 2005 to 2011. While the proportion of patients reporting the payment of informal consultation fees to providers and their amount were constant over time, the proportion of patients reporting expenditures for drugs has increased, and the median amounts have doubled from 5.3 US$to 10.7 US$. Thus, the expenditures on medicine represent the biggest financial burden for patients accessing a primary care facility. Regression models showed that in 2011 patients from the most remote district with spread-out villages reported significant higher expenditures on medicine. Besides the steady increase in the median amount for OPE, the proportion of patients reporting making an informal payment to their care provider showed great variations across district of residence (between 20% and 73%) and economic status (between 33% among the 'worst-off' group and 68% among the 'better-off' group). CONCLUSIONS: In a context of limited governmental funds allocated to health and financing reforms aiming to improve financial access to primary care, the present paper indicates that in Tajikistan OPE – especially in relation to expenditures for drugs – have increased over time, and vary substantially across geographical areas and economic status. The fact that better-off households report disbursing more and in higher proportions hints towards a discrimination along the capacity to pay from providers. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies to improve access of patients to services

Sistan (Afghan) Scrub Sparrow Passer (moabiticus) yatii: Notes on Common Name, Status and Threats

We searched for the Sistan Scrub Sparrow Passer (moabiticus) yatii in the wetlands on the Iranian side of the Sistan basin during a visit to Iran in December 2010. At least 300 Sistan Scrub Sparrows were found in the dry basin of the Hamoun-e Saberi lake. No Sistan Scrub Sparrows were found at the Chah Nimeh water reservoir, along the River Hirmand on the Afghan border and at an irrigated site near Zahak. The habitat changes caused by extreme droughts in the range of the Sistan Scrub Sparrow in recent decades are discussed. Given the small range of the species, local changes in its habitat could have devastating effects. In addition, the common name of the species is discussed. We suggest that the species be called Sistan Scrub Sparrow instead of the previous names Afghan Scrub Sparrow or Yate’s Sparrow