Tuberculosis & Universal* Health Coverage - Results Uk

08 TUBERCULOSIS AND UNIVERSAL* HEALTH COVERAGETUBERCULOSIS AND UNIVERSAL* HEALTH COVERAGE 09*TERMS & CONDITIONS APPLY.*TERMS & CONDITIONS APPLY.Chapter 1: AccessTFinding and Treating Everyone with TBSUMMARY OF SCORECARD FINDINGSACCESSFINDING & TREATING EVERYONE WITH TBINDICATORTB services areavailable inthe workplace(outside ofhealth settings).Communityhealth workersor volunteersare supportedto provide TBservices.TB preventionand screeningservices areavailable forpeople inprisons.Services areavailable toprevent TBin health careworkers.Provisions existto ensure peoplewith disabilitiescan access TBservices.Provisionsexist to ensuremigrants andrefugees canaccess nationalTB services.TB servicesare accessiblefor homelesspeople.TB servicesare adapted tothe needs ofchildren.% OF COUNTRIESTHAT INCLUDEIT IN THEIRNATIONAL POLICYDOCUMENTS66949784135944100KEY FINDINGS FROM THE SCORECARD:010203Most countries include provisionsin their policies to enablecommunity health workers orvolunteers to provide TB services.These services are often reliant onNGOs or CSOs for implementation.Community Health Volunteers(CHVs) often do not receive asalary; for example, in Kenya,any payment that CHVs receiveis dependent on donor or countygovernment initiatives ratherthan national policy.Provisions to address highexposure to TB owing to wheresomeone lives or works, such asin the mining sector, health sectorand prisons, are more commonthan provisions to addressbarriers faced by people withlimited access to services such aspeople with disabilities, migrantsand refugees, and homelesspeople. Services for people withlimited access are often reliant onsupport from external partners,for example, the InternationalOrganisation for Migration (IOM)for refugees.There is a glaring lack of anymention of specific provisionsto ensure that people withdisabilities can access services.This might be because provisionsfor people with disabilities areincluded elsewhere, such aslegal texts, but reference to suchdocuments are missing from theTB policy documents and viceversa. For example, in India “TheRights of Persons with DisabilitiesAct” stipulates that healthservices must be accessible, butthere is a lack of specific referenceto TB in the Act, or conversely anyreference to the Act in TB policydocuments. In Sierra Leone, theNational Strategic Plan referencesthe National Commission forPersons with Disabilities and theDisability Act.o find all people with TB, services must activelylook for them, understand why people are unableto access services, and implement appropriatemeasures to assist them. The Political Declarationof the UN High-Level Meeting on TB listed the peoplewho are vulnerable to TB (paragraph 17).12 It is essential that rather than just listing these groups of people,TB responses take appropriate action to address theirneeds. The 2019 Global TB Report shows that politicalwill, policy change, strategic initiatives and increasedfunding can result in finding and treating more peoplewith TB. The percentage of people with TB “missed” fellfrom 40% in 2017 to 30% in 2018 and this was helpeda strategic initiative by the Global Fund to Fight AIDS,Tuberculosis and Malaria, Stop TB Partnership and WHOthat aims to accelerate progress on finding more peoplewith TB in the 13 countries with the highest disease burden13 through initiatives such as increased communityengagement and active case finding.14This chapter and chapter 3 will outline various measuresthat must be included in TB responses if countries wantto deliver on their commitment to reach all people withTB, especially those they recognise as especially vulnerable. These vulnerable groups are often in the samerisk groups for other diseases and more likely to lackadequate access to services15 – currently over half theworld’s population lacks access to essential health services.16 As such, if health services adapt to the needs ofall people with TB, this should offer a window in to thehealth system more broadly for those currently missingout, and therefore TB can be a pathfinder for UHC.Some people have increased exposure to TB owing towhere they live or work, for example, people who live inurban slums, refugee camps or poorly ventilated or dustyenvironments, people who are contacts of individualswith TB (including children), people who work in environments that are overcrowded or are health professionals.Others have limited access to quality TB services, forexample migrant workers, women, refugees or internally displaced people, people from tribal populationsor indigenous groups, people who are homeless, peoplewho live in hard-to-reach areas, people who have mental or physical disabilities, people who face legal barri-ers to access care, or people who are LGBTQI . Stigmaattached to the disease also prevents some people fromseeking care. Investment in UHC in the form of infrastructure alone will be not be effective unless coupledwith measures to help people access services. Below area few examples of interventions.COMMUNITY HEALTH WORKERSEmpowered community health workers are essentialto help all people access services. However, despite exposing themselves to deadly diseases, their work oftendoes not result in any financial reward, so they are oftencalled Community Health Volunteers (CHVs). In Kenya,only two counties are proposing to include CHVs on thepayroll. In Kisumu, CHVs will receive 2,500 KES (approximately US 25) per month, but this is still set closer tothe value of a stipend to cover their costs than a salary.However, along with the rest of the government-paidhealth workforce in Kisumu, CHVs have faced monthswithout this payment due to delay of payments fromthe national level.17 CHVs roles are varied, from checking there is adequate clean water and sanitation in thehousehold to testing for malaria, and they are expectedto cover about 100 households per month.For TB-specific interventions, such as contact tracingand tracing people who are lost to follow up (those whodrop out of care), CHVs are supported by the GlobalFund (through Amref Health Africa). For this work, theGlobal Fund remunerates them with 840 KES (aroundUS 8.40) per person (with TB or contacts of peoplewith TB) they visit. An important part of their role is onhealth education on topics including the importance oftaking the correct doses of treatment for the recommended length of time, the importance of all contactsbeing tested for TB, and for children to start on isoniazidpreventive therapy (IPT). CHVs are chosen by their communities and are therefore trusted by the communitiesthey serve. This can be especially important for spreading awareness about the signs and symptoms of TB andthe importance of getting a diagnosis and treatment,rather than self-medicating at a pharmacy or referringthemselves to a herbal practitioner. They also help toaddress stigma around the disease within the community, dispelling myths and disseminating facts.

10 TUBERCULOSIS AND UNIVERSAL* HEALTH COVERAGETUBERCULOSIS AND UNIVERSAL* HEALTH COVERAGE 11*TERMS & CONDITIONS APPLY.Boars (left) is a 22-year old cobbler inKilala-Makueni, Kenya. He is picturedhere with his community’s healthvolunteer Stanislaus who is attachedto the Makueni County ReferralHospital. Stanislaus played a crucialrole in Boars’ successful TB treatmentbecause Boars’ community initiallyraised funds for him to access herbalisttreatment, but someone else in thecommunity was aware of Stanislaus’work and reached out to him.Stanislaus recommended that Boarsshould access treatment at the publichealth centre and he was successfullycured of TB.Boars still faced certain difficulties, forexample the 300 KES (around US 3)cost for a round-trip to the healthfacility, and the difficulty of buying thefood he was recommended toeat during treatment to help hisrecovery. He had to close his cobblersshop for 6-months.*TERMS & CONDITIONS APPLY.ADDRESSING TB IN PRISONSPeople in prisons are often at higher risk of TB due toovercrowding, low light levels, limited access to healthservices, malnutrition, alcohol and drug use, and comorbidities such as HIV. For example, in Brazil (with the thirdhighest prison population in the world),18 11% of peoplewith TB are those deprived of liberty.19 Studies in Brazilshow that targeted interventions within prisons couldhave a substantial effect on the broader TB epidemic.20 Inrecognition of this, the National TB Programme (Ministryof Health) and the Health Coordination of the NationalPenitentiary Department (Ministry of Justice) created ajoint strategy for tackling the disease, including a healtheducation campaign to raise awareness and facilitateearly diagnosis and treatment in over 1,000 prisons housing over 700,000 people, as well as their visitors.21ADDRESSING TB IN WORKPLACESOthers might be vulnerable to TB owing to the natureof their work, such as those working in mines, manufacturing jobs, and health workers. Given that TB mostlyaffects adults in their most productive years,22 it is essential that TB services are available in workplaces.In southern Africa, mining is a major driver of TB. Minesfacilitate the spread of TB due to occupational hazardsand social conditions such as high prevalence of silicosis(a lung disease caused by exposure to silica dust leadingto scarring of the lungs), high temperatures and humidity in mine shafts, and crowded working and living conditions.23 In South Africa, the TB rate among the miningworkforce is 10 times the WHO threshold for a healthemergency and nearly three times the incidence rate inthe general population.24A multi-sectoral regional initiative, the Southern AfricaTB in the Mining Sector Initiative (TIMS) aims to addressIn Kathonzweni, Makueni County Kenya, Makouis in need of psychiatric medicines for suspectedschizophrenia but lacks access. He also has TB,and is thought to have contracted it while beingremanded in police custody for four months. Hewanted to get well quicker so he could get back towork digging wells, so decided to take sixteenpills per day rather than the prescribed four.Rather than the intended effect of speeding up hiscure, it instead caused side-effects such as dizziness.this through establishing occupational health servicecentres, developing screening models for the specificcontext, conducting studies and conducting communitysystems strengthening.25 These initiatives are reflectedin several National Strategic Plans analysed in this report, such as that of Lesotho, where activities includescreening for all miners upon employment, periodicallyand at the end of the contract, as well as household contacts, and coordination with the Medical Bureau for Occupational Diseases and Compensation.Healthcare workers, including nurses, physicians, laboratory workers and community health workers, are vulnerable to TB.26 Adequate prevention measures must beput in place for them, including testing, prevention andinfection control. In Kenya, all healthcare workers aresupposed to be screened for TB every 6 months. Theyare incentivised to do this because if they contract TBand have not had a test in the last 6 months, they arenot eligible for compensation.27PEOPLE WITH DISABILITIESProvisions to ensure that TB services are accessible forpeople with disabilities varies between countries. Forexample, in Kenya it is a requirement that all health facilities are made accessible to people with physical disabilities, such as wheelchair access and accessible toiletfacilities. The Ugandan organisation MADIPHA has developed 21 recommendations for addressing disabilityin TB prevention, treatment, and care. This includes waysthat attention to disability can be better integrated intoTB programmes, and could provide a model for more explicitly linking TB guidelines with protections and entitlements for people with disabilities affected and infectedby TB. TB services must also be accessible for peoplewith intellectual disabilities and mental health problemswhich could prevent people accessing diagnosis or makeit difficult for them to complete treatment.

12 TUBERCULOSIS AND UNIVERSAL* HEALTH COVERAGE*TERMS & CONDITIONS APPLY.Chapter 2: Affordability and availabilityMONGOLIAGHANAMYANMARKENYALAO PDRZIMBABWEVIETNAMNIGERIATIMOR LESTPHILIPPINESFIJIUGANDATUBERCULOSIS AND UNIVERSAL* HEALTH COVERAGE 13*TERMS & CONDITIONS APPLY.0SUMMARY OF SCORECARD FINDINGSDirect, medicalSOCIAL PROTECTIONAVAILABILITY & AFFORDABILITY OF TB SERVICESINDICATOR% OF COUNTRIESTHAT INCLUDE ITIN THEIR NATIONALPOLICY DOCUMENTSA National PatientCost Survey hasbeen carried out/is underway/isscheduled to startin 2019 or 2020.6320406080Percentage of total costs (%)NationalHealthInsurancepolicies existand cover TBservices.47Insuranceprovisionscover loss ofincome dueto TB.34Nutritionalsupport isavailable forpeople on TBtreatment.84Financialsupport isavailable tocover transportcosts forpeople with TB.Direct, non-medical100IndirectMONGOLIAGHANAMYANMARKENYALAO PDRZIMBABWEVIETNAMNIGERIATIMOR LESTPHILIPPINESFIJIUGANDAKENYAPHILIPPINESUGANDABOX 1: WHO NATIONAL PATIENT COST SURVEYSLAO PDR06920406080Percentage of total costs (%)100FIGURE 2: DISTRIBUTIONOF COSTSDirect,FACE BYPEOPLE WITHIndirectTBDirect, medicalnon-medicalAND THEIR HOUSEHOLDS IN 12 NATIONAL SURVEYS.Source: WHO Global TB Programme, Global TB Report 2019.KEY FINDINGS FROM THE SCORECARD:010203Key social interventions,including nutrition supplementsand support for transport costsare often limited in their scope,for example only for people withdrug-resistant TB rather thanall people with TB. Of countriesproviding nutrition support,this is limited to people withdrug-resistant TB in a third ofthem. Of countries providingtransport support, this is limitedto people with drug-resistantTB in half of them.Despite the existence in officialpolicy of various social interventions, their implementationis dependent on health systemsthat can ensure their supply. Forexample, the delivery of nutritionsupplements relies on nationalprocurement and supply agenciesto deliver them to where they areneeded. In Kenya, health centresacross the country have notreceived nutrition supplementsfor up to a year or have receivedsupplements that are tooclose to their expiry date to bedispensed.28Nutrition and transport interventions are wholly funded byexternal donors in many of theplans analysed in the scorecard,meaning that their sustainabilityrelies on governments takingup responsibility for them oncedonors withdraw funding.For example, in Namibia, bothnutrition and transport supportare listed in their NationalStrategic Plan up to 2022 asprovided by the Global Fund.However, those activities are nolonger being implemented dueto a reduction in funding, andhave not been taken up by theMinistry of Health.29and loss of income. A study by Wingfield, based on 32shantytown communities in Peru,34 argues that beyondcatastrophic costs to families, TB-related costs causeother adverse outcomes including multi-drug resistantTB. Socio-economic interventions in such householdsreduce the likelihood of incurring catastrophic costs, increase the chances of contacts accessing TB preventivetherapy, and lead to a greater chance of cure.35Every year, almost 100 million people are pushedinto extreme poverty by out-of-pocket healthcareexpenses.30 TB is not only a consequence of poverty, but also a cause. This chapter will assess various social protection interventions, sometimes called“enablers,”31 that are essential to prevent such costs occurring. National Health Insurance schemes or UHC programmes help to address direct medical costs (consultations, diagnosis, medicines, etc.), but countries mustalso consider direct non-medical costs (e.g. transport,food) and indirect costs (such as loss of income) associated with the disease when designing such schemes.32Investment in social protection interventions across direct medical, direct non-medical and indirect costs willbe essential to prevent costs to individuals.The need to go beyond addressing direct medical coststhrough health insurance is clear for TB. Despite diagnosis and treatment being available free of charge33 inmany of the countries surveyed in this report, significant costs can be incurred before a correct TB diagnosis,for example, due to the need for several trips to a healthcentre with incorrect diagnoses or self-prescribing atthe local pharmacy. Costs associated with TB treatmentalso contribute significantly, such as purchasing theadditional nutrition supplements that are prescribed,transport costs to health centres during treatment,WHO’sNational Patient Cost surveys36 for TB aimVIETNAMto find out the causes of out-of-pocket paymentsandGHANAwho incurs them. These findings must bediscussed in a multi-sectoral fora and acted on toMONGOLIAaddressthe drivers of costs for people with TB andtheirfamilies. The surveys should inform policies toNIGERIAhelp mitigate costs by improving approaches to TBservicedelivery and financing, and any remainingZIMBABWEcosts should be mitigated by social protectionmeasures in0collaboration25 with stakeholders5075 across100the social sector.Percentage facing catastrophic costs (%)AllDS-TBDS-TB (urban)DS-TB (rural)TB-HIVDR-TBKENYAPHILIPPINESUGANDALAO 075100Percentage facing catastrophic costs (%)DS-TB (urban)DS-TB (rural)TB-HIVDR-TBFIGURE 3: ESTIMATES OF THE PERCENTAGE OF PEOPLEWITH TB AND THEIR HOUSEHOLDS FACING CATASTROPHICCOSTS DUE TO TB DISEASE IN 12 NATIONAL SURVEYS (BESTESTIMATES AND UNCERTAINTY INTERVALS SHOWN).Source: WHO Global TB Programme, Global TB Report 2019.

14 TUBERCULOSIS AND UNIV

respect for human rights, the effective rule of law, good governance, and effective and accountable institutions. UHC is the outcome of investments in people-centred services with participation and dialogue as underlying principles."5 This report argues that, when done delib-erately and well, investing in people-centred TB services