Houben, R

Lönnroth, Knut

Pedrazzoli, D

Viney, K

The International Journal of Tuberculosis and Lung Disease

English

LSHTM Research Online

  Correspondence  Title: Beyond measurement: taking bold multisector actions towards zero catastrophic costs and suffering due to TB  Authors: Debora Pedrazzoli1*, Rein Houben1, Kerri Viney2,3, Knut Lönnroth2  Authors’ affiliations 1. Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom 2. Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden  3. Research School of Population Health, Australian National University, Canberra, Australia   *Correspondence to: Debora Pedrazzoli, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom. E-mail: debora.pedrazzoli@lshtm.ac.uk  Running head: Multisector actions against TB Key words: tuberculosis; patient costs; financial protection, social protection  Word count: 533 References: 5    2 We agree with Timire and colleagues that all financial barriers faced by people with TB at all stages of 1 the care cascade should be addressed if we are to achieve the ambitious targets set by the End TB 2 Strategy and the Sustainable Development Goals. Further evidence on economic hardship during 3 pathways to care, and also after treatment completion, is warranted. Several studies are ongoing, 4 including “TBSequel”, which tracks costs after completed TB treatment in four African countries (1).  5  6 Although national TB patient cost surveys focus on diagnosed TB patients, they also aim to capture 7 retrospective information about pre-diagnosis costs related to seeking care (2). In addition, the survey 8 instrument can be incorporated into patient pathway analyses, prospective studies and trials and 9 thereby provide important complementary information.  10  11 The design and sampling strategy are as important as the choice of the instrument. Even studies with 12 inception during the diagnostic pathway will inevitably miss those that never seek or receive any care, 13 or do so at facilities that are not captured in the study design. Prospectively collecting patient costs 14 from symptomatic individuals as part of a TB prevalence survey is an attractive design, but challenging 15 to implement, due for instance to the geographical spread of small numbers of untracked patients.  16  17 We welcome the suggestion from Timire and colleagues for more evaluations of different social 18 protection interventions. Findings from ongoing or planned intervention studies in e.g. Vietnam, 19 Nepal, Uganda and Mozambique, aiming to improve completion of the care pathway through different 20 modalities of socioeconomic support  will contribute important evidence. Several of these studies are 21 linked to the Social Protection Action Research & Knowledge Sharing (SPARKS)(3), an international 22 interdisciplinary research network on social protection, aiming to facilitate networking and knowledge 23 sharing between academia, public health practitioners, international organizations and civil society. 24 Government-led schemes such as the Direct Benefit Transfer in India may encourage people to engage 25 with care, thus addressing another gap that is not tackled by looking at individuals who are lost to 26 follow-up pre-treatment. This potential needs rigorous evaluation.  27  28 TB patient cost surveys provide important information on how health service delivery and financing 29 can be changed towards patient-centred care to eliminate TB patient costs, as well as enhancing social 30 protection measures(2). They are a powerful tool to draw focus towards eliminating the financial 31 plight and barriers for presumptive and TB patients, through collaboration with relevant stakeholders 32 within and across the health sector. 33  34   3 For example, addressing pre-diagnosis medical costs involves streamlining the TB patient pathway, 35 expanding access to rapid molecular testing and digital X-rays, intensifying contact investigation and 36 case finding(4), looking for synergies with programmes on HIV, nutrition, diabetes. 37  38 Ghana, the first country in Africa to conduct a national TB patient cost survey(5), recently developed 39 a national roadmap to eliminate financial catastrophe for TB patients through a broad multi-sectoral 40 agenda. The first policy action of this roadmap has led to the decision of the Ghana National Health 41 Service and National Health Insurance Authority to enrol all TB patients in the National Health 42 Insurance Scheme free of charge. This should serve as an example and reminder to other countries 43 and technical partners that ongoing efforts to measure TB-related costs can, and should lead to even 44 greater concerted efforts to take bold actions towards zero catastrophic costs due to TB, zero TB 45 suffering and ultimately TB elimination.46   4 References  1. Rachow A, Ivanova O, Wallis R, Charalambous S, Jani I, Bhatt N, et al. TB sequel: incidence, pathogenesis and risk factors of long-term medical and social sequelae of pulmonary TB - a study protocol. BMC Pulm Med. 2019;19(1):4. 2. World Health Organization. Tuberculosis patient cost surveys: a handbook. Geneva, Switzerland2017. 3. Health and Social Protection Action Research & Knowledge Sharing (SPARKS) Network. Rationale, Objectives and Work Plan. Report from the first SPARKS consultation 15-16 December, 2016. 2017. 4. Morishita F, Yadav RP, Eang MT, Saint S, Nishikiori N. Mitigating Financial Burden of Tuberculosis through Active Case Finding Targeting Household and Neighbourhood Contacts in Cambodia. PloS one. 2016;11(9):e0162796. 5. Pedrazzoli D, Siroka A, Boccia D, Bonsu F, Nartey K, Houben R, et al. How affordable is TB care? Findings from a nationwide TB patient cost survey in Ghana. Tropical medicine & international health : TM & IH. 2018;23(8):870-8.  

Beyond measurement: taking bold multisector actions towards zero catastrophic costs and suffering due to TB.

Houben, R M

Viney, Kerri

Lonnroth, Knut

The Australian National University

Beyond measurement: taking bold multisectoractions towards zero catastrophic costs andsuffering due to TBWe agree with Timire et al. that all financial barriersfaced by people with tuberculosis (TB) at all stages ofthe care cascade should be addressed if we are toachieve the ambitious targets set by the End TBStrategy.1 Further research into economic hardshipduring pathways to care, and also after treatmentcompletion, is warranted. Several studies are ongo-ing, including ‘TBSequel’, which tracks costs aftercompleted TB treatment in four African countries.2Although national TB patient cost surveys focus ondiagnosed TB patients, they also aim to captureretrospective information about pre-diagnosis costsrelated to seeking care.3 In addition, the surveyinstrument can be incorporated into patient pathwayanalyses, prospective studies and trials, and thereby,provide important complementary information.The design and sampling strategy are as importantas the choice of the instrument. Even studies withinception during the diagnostic pathway will inevita-bly miss those that do not seek or receive any care, ordo so at facilities that are not captured in the studydesign. Prospectively collecting patient costs fromsymptomatic individuals as part of a TB prevalencesurvey is an attractive design, but challenging toimplement, due for example, to the geographicalspread of small numbers of untracked patients.We welcome the suggestion by Timire et al. formore evaluations of different social protectioninterventions. Findings from ongoing or plannedintervention studies (such as in Viet Nam, Nepal,Uganda and Mozambique), aiming to improvecompletion of the care pathway through differentmodalities of socio-economic support will contributeimportant evidence. Several of these studies are linkedto the Social Protection Action Research & Knowl-edge Sharing (SPARKS),4 an international interdisci-plinary research network on social protection, aimingto facilitate networking and knowledge sharingbetween academia, public health practitioners, inter-national organisations and civil society. Government-led schemes such as the Direct Benefit Transfer inIndia may encourage people to engage with care, thusaddressing another gap that is not tackled by lookingat individuals who are lost to follow-up pre-treat-ment. This potential needs rigorous evaluation.TB patient cost surveys provide important infor-mation on how health service delivery and financingcan be changed towards patient-centred care toeliminate TB patient costs, as well as enhancingsocial protection measures.3 They are a powerfultool, allowing us to focus on solving the financialplight and eliminating the barriers for presumptiveand TB patients through collaboration with relevantstakeholders within and across the health sector. Forexample, addressing the problem of pre-diagnosismedical costs involves streamlining the TB patientpathway, expanding access to rapid molecular testingand digital X-rays, intensifying contact investigationand case finding,5 looking for synergies with pro-grammes on HIV, nutrition and diabetes.Ghana, the first country in Africa to conduct anational TB patient cost survey,6 recently developed anational roadmap to eliminate financial catastrophefor TB patients through a broad multisectoral agenda.The first policy action of this roadmap has led to thedecision of the Ghana National Health Service andNational Health Insurance Authority to enrol all TBpatients in the National Health Insurance Scheme—free of charge. This should serve as an example andreminder to other countries and technical partnersthat ongoing efforts to measure TB-related costs canand should promote bold action to eliminate thecatastrophic costs and suffering due to TB, andultimately lead to TB elimination.D. PEDRAZZOLI1R. HOUBEN1K. VINEY2,3KNUT LÖNNROTH21Department of Infectious Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondon, UK2Department of Public Health SciencesKarolinska InstitutetStockholm, Sweden3Research School of Population HealthAustralian National UniversityCanberra, ACT, Australiae-mail: debora.pedrazzoli@lshtm.ac.ukhttp://dx.doi.org/10.5588/ijtld.19.0282Conflicts of interest: none declared.References1 Timire C, Sandy C, Harries A D. Eliminating tuberculosis by2035: tackling the financial barriers at all stages of the cascade ofcare. Int J Tuberc Lung Dis 2019; 23: 1235.2 Rachow A, Ivanova O, Wallis R, et al. TB sequel: incidence,pathogenesis and risk factors of long-term medical and socialsequelae of pulmonary TB: a study protocol. BMC Pulm Med2019; 19(1): 4.3 World Health Organization. Tuberculosis patient cost surveys: ahandbook. Geneva, Switzerland: WHO, 2017.4 Health and Social Protection Action Research & KnowledgeSharing (SPARKS) Network. Rationale, objectives and workplan. Report from the first SPARKS consultation, 15–16December 2016. Stockholm, Sweden: SPARKS, 2017.5 Morishita F, Yadav R P, Eang M T, Saint S, Nishikiori N.Mitigating financial burden of tuberculosis through active casefinding targeting household and neighbourhood contacts inCambodia. PLoS One 2016; 11(9): e0162796.6 Pedrazzoli D, Siroka A, Boccia D, et al. How affordable is TBcare? Findings from a nationwide TB patient cost survey inGhana. Trop Med Int Health 2018; 23(8): 870–878.1236 The International Journal of Tuberculosis and Lung Disease

Beyond measurement: taking bold multisector actions towards zero catastrophic costs and suffering due to TB

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Beyond measurement: taking bold multisector actions towards zero catastrophic costs and suffering due to TB.

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