Addressing socioeconomic hardship associated with TB in Brazil
In Brazil, people with tuberculosis (TB) often incur substantial costs related to seeking and receiving diagnosis, treatment, and care. Such costs may create access to care barriers that adversely affect health outcomes and increase the risk of disease transmission. Eliminating catastrophic costs for people with TB and their households with effective mitigation strategies and policies is crucial. The WHO End TB Strategy includes a target to ensure that no TB-affected households face catastrophic costs due to the disease. To support and monitor achievement of this strategic ambition, WHO established standard methods for conducting national surveys of direct and indirect costs faced by TB patients and their households [1]. Since 2015, WHO has provided survey implementation guidance to national TB programmes and local research teams. The Global TB Programme provided direct technical assistance for the national TB patient cost survey in Brazil and participated in Pan American Health Organization (PAHO)/WHO co-organized post-survey events (October 2021 and March 2022) to discuss the use of survey evidence for health and social policy change.
How did Brazil do it, and how did the WHO Secretariat support Brazil?
The National TB Programme (NTP) of Brazil, in collaboration with the University of Espirito Santo (Vitoria, Brazil) and with technical assistance from the Global TB Programme, conducted a national survey between 2019 and 2021. A total of 603 people diagnosed with TB across the country participated. Although data collection was severely disrupted on many occasions due to the COVID-19 pandemic, the survey was successfully completed. Extensive support to implement the survey and address COVID-related bottlenecks was provided by the three levels of WHO: the headquarters-based Global TB Programme provided technical support and policy recommendations, the WHO Regional Office for the Americas (PAHO), and the PAHO/WHO Country Office in Brazil secured survey funding, monitored survey implementation and hosted post-survey events, which aimed to highlight research leading to policy development.
The survey found that about half (48%) of TB-affected households in Brazil faced catastrophic costs, defined as having experienced costs above 20% of their annual household income during their TB episode. On average, patients incurred costs (direct and indirect costs) amounting to 1573 US dollars throughout the TB episode, from onset of symptoms to treatment completion. The largest per episode cost (1030 US dollars), an indirect cost, was incurred as a result of the difference in income before and during the TB episode. TB episode related expenses for nutritional supplements required to increase immunity and compensate for severe weight loss as well as travel costs incurred for clinic visits and other non-medical costs were on average 422 US dollars. Out-of-pocket medical spending amounted to 122 US dollars per episode.
Findings from the survey further revealed that to mitigate such costs, one-third of TB-affected households in Brazil had to borrow or sell assets to cope with economic hardship. In addition, poverty levels almost doubled in households as patients entered TB care, with one in four TB-affected patients living below the international poverty line (that is 1.90 US dollars per day). The ability to secure jobs for TB patients was also affected, with employment falling from 68% to 48%, presumably due to insufficient levels of protection from job losses when affected by TB. Every month during TB treatment, a patient in Brazil lost on average 115 US dollars. The survey also found that the risk of households facing unaffordable costs increased for those with HIV co-infection, the self-employed, and people with lower levels of education.
While TB care in the Brazilian public health sector is free of charge, the survey showed that the availability of free diagnosis and treatment services does not prevent high financial burden for people with TB. It also showed that TB has social, income, employment, and poverty consequences, as well as potential long-lasting effects and social sequelae that require a multisectoral response. Survey findings and suggested policy recommendations are being disseminated in different fora with participation or co-hosting from the three levels of WHO. An October 2021 event for ministries of citizenship and health was attended by all TB programme coordinators across the country. Findings were presented at the 57th Congress of the Brazilian Society of Tropical Medicine [2], where translating evidence into policy was discussed. On 29 March 2022, a one-day national event, entitled “Addressing socio-economic hardship associated with TB in Brazil” [3], was co-hosted by the Ministry of Health and the PAHO/WHO Country Office in Brazil. The event engaged a wide range of stakeholders, including local TB programme staff, health service managers, researchers, intersectoral and civil society partners. The event was supported by the Global TB Programme with policy and survey methods presentations delivered by the Global TB Programme’s Director and key technical staff, as well as by PAHO with the Regional Advisor for the Tuberculosis Programme presenting on “Tuberculosis and social determinants”.
Further dissemination in a scientific journal and at national meetings is planned for 2022. The evidence stemming from this survey is being used to design measures to alleviate the burden of disease on TB patients and their households, which will also promote multisectoral collaboration beyond health in Brazil.
REFERENCE
[1] World Health Organization. Tuberculosis patient cost surveys: a handbook. Geneva: World Health Organization; 2017. Available from: https://www.who.int/publications/i/item/9789241513524.
[3] http://webinar.aids.gov.br/
Photo Credit: © Data collection team of the national TB patient cost survey, Brazil
Photo Caption: Leticya and Sonia, researchers from the Brazil national TB patient cost survey, interviewing a patient in Valença, Bahia, Brazil.