OURJEET - SANDOZ | TB and Poverty

The Poverty Cycle

The economic impact of tuberculosis is staggering. TB overwhelmingly affects the poor and it infects people in their most productive years.

90 percent of TB cases and 98 percent of TB deaths occur in developing countries, while 75 percent of fatal cases occur in people between the ages of 15 and 54.

Drug-susceptible TB treatment is often free, but patients incur other costs, like transportation, hospital stays, and reduced working hours. The WHO calculates that the average TB patient loses three to four months of work-time, and up to 30 percent of yearly household earnings. TB annually robs the world's poorest communities of an estimated US$12 billion in lost income. Poor, crowded living conditions also increase the risk of contagious infection. TB creates a vicious circle: the disease exacerbates poverty, which in turn increases the likelihood of contracting TB.

The World Bank estimates that loss of productivity attributable to TB is four to seven percent of some countries' GDP. Entire economies are affected, stifling human development on a large scale. Meanwhile, the burgeoning cost of TB medical care is a constant drain on those health systems whose infrastructures are least able to carry the load.

Given the direct link between TB and poverty, a faster, better cure could provide immediate benefits. A shorter drug regimen would reduce lost work-time and lessen the burden on patients. Healthcare systems would see dramatic savings: the infrastructure necessary for TB treatment represents the bulk of their costs — about $4 billion annually. A shorter regimen that eliminates many of the doctor visits could drastically cut those expenses. Funding could then be redirected to basic healthcare and increased resources for TB control. Whole economies would benefit, especially in nations that bear the brunt of the TB pandemic.

Poverty

The association between poverty and TB is well established. Even within the developedworld the highest rates of disease are seen in the poorest sections of the community. As the world population increases in some of the poorest areas of the world so the number of people living in poverty has increased.
In the last 15 years the number of people living on less than a dollar a day (the definition of absolute poverty) has increased from three-quarters to one and a third billion. More than three-quarters of these are women. The proportion of the world's wealth owned by the richest 20% has increased from 65% to over 85% in the same time period. Though we do not have hard data to show that TB increases as poverty increases but common sense tells us that it does.

Programme decline

The overwhelming problem with the treatment of TB is that cure takes 6 months of treatment. The great majority of people suffering from TB are amongst the poorest health care facilities in the world. The great majority do not therefore complete their treatment. Premature cessation of treatment will result in relapse and possibly the emergence of drug resistance. Programmes to ensure that all patients received adequate supplies of good quality drugs effectively broke down in many countries by the 1980s.Very belatedly new programmes are being geared up but the resources needed are often beyond the scope of the countries and communities that are worst affected.

Vicious Circle

Together, poverty and the tubercle bacillus create another vicious circle. Poor people, plagued by hunger and crowded into close, unhygienic quarters, are easy victims in an environment where TB flourishes. Once taken ill with TB, people's capacity to work is diminished even as treatment expenses spiral, exacerbating their poverty. Meanwhile, the poor receive inadequate health care that often inhibits the TB detection in the first place. Treatment is often inconsistent and/or incomplete to non-existent. The poor are less likely to seek and receive proper care when ill, exacerbating the impact of the disease. In addition, they are two to three times more likely than other income groups to self-medicate. Self-medication and partial treatment encourage the emergence of drug-resistant TB strains, further increasing the impact on the poor and the risks to others in society.

Links between TB and Poverty

The global experience with TB control has been able to define certain clear-cut linkages between TB and poverty:

TB is more prevalent among low-income groups than among high-income groups.
The cost of TB care, if borne by families alone can be unaffordable.
TB is a chronic ill ness and requires care over a relatively long period-during which productivity is reduced, leading to interruption of education and work.
Household income is severely reduced, family dysfunction increases, particularly if mothers are ill and poverty increases.
Lower productivity and more poverty impede social and economic development and increase inequalities in society.
Lower income people are higher risk-as TB spreads in crowded places-households, school, workplace, marketplace and commuting between them.

TB drug: CSIR on the verge of breakthrough

KARAIKUDI: The Council of Scientific and Industrial Research (CSIR) is developing an indigenous drug for tuberculosis under `drugs for the poor' programme that brings together public-private partnership in the pharmaceutical research.
"The TB drug is undergoing first phase of clinical trials at the CSIR laboratories and a breakthrough is expected soon", the CSIR Director-General, R.A. Mashelkar, said here on Sunday.

In an exclusive interview to The Hindu during his visit to the Central Electrochemical Research Institute (CECRI) here, Dr. Mashelkar said the country's premier body for scientific research was bringing together traditional medicine, modern medicine and science for the drug development programme that had now reached an advanced stage.
He pointed out that a TB drug in the current context became indispensable since the last time a drug for tuberculosis came out was in the year 1963.

"Our drug means a lot not only to the large number of Indian patients but also to the entire African region, plagued with TB in the background of HIV-AIDS," he said.
Stating that the final process of the new drug could be completed in four years after multiple lab trials, Dr. Mashelkar said he was "very optimistic" of the end result due to the progress made so far.

According to him, the CSIR's TB drug is expected to be more effective to patients with regard to time taken for treatment/cure. While normally it takes eight to ten months to recover despite a heavy daily dosage, "a TB patient with our drug can feel much better in two months time," he said and added that a substantial budget allocation was made for the drug.

Several reputed pharmaceutical companies in the country were also involved in the project going on under the CSIR banner of New Millennium technology initiative.
Civil aviation Dr. Mashelkar said the CSIR was also playing an active role in the aviation sector that was now seeing a boom in the country. Technology for small flights connecting short distance destinations is one area it was working on at present and the "substance of our work is to create products that India needs."

During his visit to CECRI campus, he interacted with scientists and officials, and also addressed them on the issue of global competitiveness, passion, inspiration and compassion.

What is the relationship between TB and poverty?

The cycle of TB and poverty

A symbiotic relationship exists between TB and poverty.New TB infection is not just the product of poverty, but also creates poverty. Understanding the connection between TB and poverty is a powerful first step towards breaking this vicious cycle. Fighting TB and poverty together is necessary to accelerate economic and social growth and consequently reduce the global burden of TB.
Poverty fuels tuberculosis

TB is a disease of poverty. It is widely recognised that the poorer the community, the greater the likelihood of being infected with the TB germ and developing clinical disease.

• A lack of basic health services, poor nutrition and inadequate living conditions all contribute to the spread of TB and its impact upon the community.

• An absence of good quality health care facilities is common in poor communities.With no health services to diagnose or treat patients, there is a longer delay between disease and cure, perpetuating the spread of TB.

o Poor nutrition and an inadequate diet weaken the immune system and increase the chances of infection and developing active TB.

o Overcrowded and poorly ventilated home and work environments make TBtransmission more likely.

o “The poor lack access to essential medicines for reasons including poverty itself, lack of outreach, shortages of health workers, taxes and duties on imported drugs, and burdensome procedures. These reasons apply to TB drugs, even thosethat are off-patent.”

Tuberculosis fuels poverty
The economic and human impact of TB is many times greater on poor households and poor nations than on the developed world. The high incidence levels of TB found in many poor nations means a sick labour force, extra strain on limited health services and shackled economic growth.

• The burden of TB is estimated to swallow an economic toll of US$12 billion from the incomes of the world’s poorest communities every year.

• Studies suggest that the average patient loses three to four months of work time as a result of TB. Lost earnings can total up to 30% of annual household income.

• In economic terms, TB decreases the output of a country’s labour force and consequently reduces its gross domestic product.

• “ TB is a giant poverty producing mechanism.”

Next steps in fighting TB and poverty
• Emphasising the fact that poverty contributes to the spread of TB and that TB contributes to the ersistence of poverty stimulates a global dialogue which is highly relevant both to reversing the spread of TB and to poverty reduction.

• The global strategy to fight the TB epidemic and expansion of DOTS are ways to fight TB and alleviate poverty and inequity.

• By securing global political resolve and mobilising an adequate flow of resources from high-income to low-income countries we can tackle TB and poverty together.

Who is most vulnerable to TB and what can we do about it?

TB control and poverty reduction cannot be achieved by concentrating on improving averages across the general population. TB control needs to address the specific needs of vulnerable communities. Directly Observed Treatment Strategy (DOTS) case detection and treatment success rates are well below targets in some regions, and it is the poorest and most vulnerable people who are unable to access care and treatment services. TB control efforts need to bring these services closer to those who need it most.

For More Information Visit : http://www.equi-tb.org.uk/uploads/tb_vulnerable.pdf#search=%22TB%20in%20vulnerable%20communities%22

TB and Poverty Action Plan

The Global Plan to Stop TB aims to ensure equitable access to quality TB care for all people with TB, especially the poor and vulnerable. It sets the following targets:

By 2010 all countries will:

have developed capacity to monitor the extent to which TB control reaches and serves the poor and vulnerable and
have developed key strategies for improving access to TB control for the poor and vulnerable.

By 2015 all countries will have developed the capacity to demonstrate and monitor the contribution made by TB control to poverty alleviation.

The development and publication by WHO of the manual for use by national TB control programme in addressing poverty in TB control, provides the first step to achieving the Global Plan targets. The manual defines poverty in terms of both economic and social aspects (exclusion from services and opportunities due to gender, race, ethnicity, religion, education level or residence urban/rural). Consequently it outlines measures aimed both at reducing the financial burden of TB care (e.g. shifting from out-of-pocket expenditure to public financing, reduction of treatment delays and provision of incentives and enablers) and tackling the social aspects of poverty (e.g. addressing stigma and the lack of knowledge of TB and available services). The manual is necessary in addressing poverty in TB control and DOTS Expansion, but not sufficient: explicit support is required for mechanisms that ensure active use of the manual and the options laid out within it. Furthermore, current restrictions on the access of poor people to TB services should not be underestimated and cannot be addressed solely within DOTS Expansion. Poor people with HIV/TB and MDR-TB require particular attention due to the complexity of their diagnostic and treatment needs and the high socio-economic impact of their more complex disease burden. Furthermore the limitations placed by current TB vaccines, diagnostics, and drugs on services in resource-poor settings are considerable. Equity measures are clearly needed both in the development and delivery of new tools for TB Control.

This Action Plan for TB & Poverty responds to the needs of the poor and vulnerable with TB and proposes actions which are relevant and must engage across all 7 Working Groups of the STOP-TB Partnership

Purpose

The purpose of this Action Plan is the promotion of global access to quality diagnosis and treatment of TB for the poor and vulnerable in line with the STOP TB strategy and the Second Global Plan to Stop TB.

Outputs

The Purpose of the Plan will be achieved through delivery of the following outputs:

An inventory of existing strategies for addressing poverty and enhancing equity in health service delivery appraised for their relevance to implementation of the STOP-TB Strategy.
A set of indicators and methodologies for assessing equity of access and financial protection that can be used as part of the evaluation of TB control.
Documentation of the special access barriers and financial burden faced by patients with TB-HIV co-infection and MDR-TB.
Enhanced capacity and technical assistance for implementing and evaluating pro-poor strategies in TB control (including implementation of the WHO Guide "Addressing Poverty in TB Control".)
Evaluation of the equity-enhancing effects of existing interventions (e.g. Public-Private Mix [PPM], Practical Approach to Lung Health [PAL] and FIDELIS)
Strategies to enhance equitable access to the new tools for TB control through the New Tools Working Groups of the STOP-TB Partnership.
Development of new pro-poor approaches relevant to the implementation of the STOP-TB Strategy.

These Outputs work together to achieve the Purpose through a modified "equity loop" as illustrated in the Figure:

Further description of the Outputs

An inventory of existing strategies for addressing poverty and enhancing equity in health service delivery appraised for their relevance to implementation of the STOP-TB Strategy. The aim here is to learn from experience and published evidence from outside the field of TB control and appraise this experience from the perspective of TB control so as to flag and prioritise key approaches that are not already covered in "Addressing Poverty in TB Control".
A set of indicators and methodologies for assessing equity of access and financial protection that can be used as part of the evaluation of TB control. Many of the indicators in current use are context-specific. We are looking to develop some common tools that can be used widely in evaluation of TB control through the conduct of surveys of already-diagnosed TB patients and through community-based TB prevalence surveys.
Documentation of the special access barriers and financial burden faced by patients with TB-HIV co-infection and MDR-TB. Most of the existing work on barriers faced by TB patients has been synthesised for TB patients but with insufficient attention on the additional barriers faced by TB-HIV and MDR-TB patients.
Enhanced capacity and technical assistance for implementing and evaluating pro-poor strategies in TB control (including implementation of the WHO Guide "Addressing Poverty in TB Control".) The aim here is to develop course materials and a training module for use at country level to promote the use of the WHO Guide with the intention of promoting wider implementation of pro-poor approaches mainstreamed within TB control activities on the ground.
Evaluation of the equity-enhancing effects of existing interventions (e.g. Public-Private Mix [PPM], Practical Approach to Lung Health [PAL] and FIDELIS) The aim here is to promote the use of the indicators developed in Output 2 in the evaluations being conducted of existing interventions aimed at extending the REACH of TB control. Members of the TB & Poverty Subgroup will work with implementation teams (e.g. PPM) to mainstream the use of relevant indicators in their evaluations.
Strategies to enhance equitable access to the new tools for TB control through the New Tools Working Groups of the STOP-TB Partnership. This output links closely to the work of the "Task force on re-tooling" and will be informed by the outputs of that task force.
Development of new pro-poor approaches relevant to the implementation of the STOP-TB Strategy. The intention is that all of Outputs 1-6 are appraised together in order to inform the development and piloting of new pro-poor approaches or modifications to existing approaches which can be piloted and implemented, particularly in poor countries carrying a high burden of TB.

Role and Responsibility of the TB & Poverty Subgroup in relation to the other Working Groups and Partners of the STOP-TB Partnership in delivering the Action Plan.

The prime role of the Subgroup is in promoting and stimulating pro-poor TB control. The Subgroup cannot itself be responsible for implementation on the ground. This is the province of the Implementation Working Groups and TB programmes at country level and beyond. The TB & Poverty Subgroup will use its network of individuals and organisations who also have roles in all the other Working Groups of the Partnership and within implementing bodies to promote activity on the ground leading to piloting in selected sites to be decided upon in Years 2 and 3.

Implementation of the Action Plan

Different organisations currently active in the TB & Poverty Sub-group have participated over the past year in developing this Action Plan. Each output will now become the prime responsibility of a particular organisation which has volunteered to work to define in more detail the activities required to deliver the output. The agreed principles for further development of the activity plans for each output are:

a) That developing country organisations must play a prominent role.
b) That more detailed activity plans will be reviewed and modified by the TB & Poverty Core Team supported by external independent reviewers

The Secretariat of the TB and Poverty Sub-Group, will take responsibility for holding and disbursing the requested budgetary allocation against the more detailed action plans as they are approved. The Secretariat will also be responsible for compiling progress reports for presentation to the TB & Poverty Core Team (see also new Terms of Reference for TB & Poverty Sub Group).
Click here for the list of responsible agencies.

Activities

Broad activity descriptions have been grouped according to outputs, mapped to the responsible agencies within the TB & Poverty Sub-Group, and projected over the 5-year time period of the Action Plan. More detailed activity plans with specific Terms of Reference will be co-ordinated by the lead agency for each of the Outputs and Reviewed by the TB & Poverty Core Team, plus independent advisors.

More detail is given about the early outputs and activities which are deliverable within the first 2 years of the action plan. Details about later activities and outputs will be developed at a mid-term review of progress against the Action Plan.
Click here for the list of activities.

Practical steps to address poverty in TB Control

Steps involved

Chapter 1	Identification of the poor and vulnerable groups in the country/region served by the national TB control programme
Chapter 2	Identification of the barriers to accessing TB services faced by the poor and vulnerable groups in the country/region
Chapter 3	Identification of potential actions to overcome the barriers to access
Chapter 4	Situations and population groups requiring special consideration
Chapter 5	Harnessing resources for pro-poor TB services
Chapter 6	Assessment of the pro-poor performance of the national TB control programme and the impact of pro-poor measures

Click here to view the list of steps involved in pdf format

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