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Open Access Research article

Assessing access barriers to tuberculosis care with the Tool to Estimate Patients' Costs: pilot results from two districts in Kenya

Verena Mauch1*, Naomi Woods2, Beatrice Kirubi3, Hillary Kipruto45, Joseph Sitienei4 and Eveline Klinkenberg16

Author Affiliations

1 KNCV Tuberculosis Foundation, Den Haag, The Netherlands

2 Merlin, Goma, DR Congo

3 Gertrude's Children's Hospital, Nairobi, Kenya

4 Ministry of Public Health and Sanitation Kenya, Division of Leprosy, Tuberculosis and Lung Disease, Nairobi, Kenya

5 World Health Organization Kenya, Nairobi, Kenya

6 Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

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BMC Public Health 2011, 11:43  doi:10.1186/1471-2458-11-43

Published: 18 January 2011

Abstract

Background

The poor face geographical, socio-cultural and health system barriers in accessing tuberculosis care. These may cause delays to timely diagnosis and treatment resulting in more advanced disease and continued transmission of TB. By addressing barriers and reasons for delay, costs incurred by TB patients can be effectively reduced. A Tool to Estimate Patients' Costs has been developed. It can assist TB control programs in assessing such barriers. This study presents the Tool and results of its pilot in Kenya.

Methods

The Tool was adapted to the local setting, translated into Kiswahili and pretested. Nine public health facilities in two districts in Eastern Province were purposively sampled. Responses gathered from TB patients above 15 years of age with at least one month of treatment completed and signed informed consent were double entered and analyzed. Follow-up interviews with key informants on district and national level were conducted to assess the impact of the pilot and to explore potential interventions.

Results

A total of 208 patients were interviewed in September 2008. TB patients in both districts have a substantial burden of direct (out of pocket; USD 55.8) and indirect (opportunity; USD 294.2) costs due to TB. Inability to work is a major cause of increased poverty. Results confirm a 'medical poverty trap' situation in the two districts: expenditures increased while incomes decreased. Subsequently, TB treatment services were decentralized to fifteen more facilities and other health programs were approached for nutritional support of TB patients and sputum sample transport. On the national level, a TB and poverty sub-committee was convened to develop a comprehensive pro-poor approach.

Conclusions

The Tool to Estimate Patients' Costs proved to be a valuable instrument to assess the costs incurred by TB patients, socioeconomic situations, health-seeking behavior patterns, concurrent illnesses such as HIV, and social and gender-related impacts. The Tool helps to identify and tackle bottlenecks in access to TB care, especially for the poor. Reducing delays in diagnosis, decentralization of services, fully integrated TB/HIV care and expansion of health insurance coverage would alleviate patients' economic constraints due to TB.