MDR-TB Treatment & Prevention

Having worked in the TB control program in Nigeria for many years, my experience is similar to what Jean Baptiste Mulongo is reporting from the DRC.
Some patients on treatment have been found to stop treatment on account of inability to pay for some "hidden" costs even though TB treatment is officially free of charge. These hidden costs are sometimes justified by those demanding them for so many reasons e.g stock out of program drugs and reagents and materials so the hospital has to source them from the open market to continue treatment until their stock is replenished.

There are several other reasons for charging patients including under the table demands from some hospital staff which forces some patients to stop treatment especially after they have taken treatment for some time, have probably converted to sputum smear negative and are feeling better. As we know this is a veritable recipe for the development of drug resistance TB.
I have always argued that the fight against MDRTB should begin upstream by trying to stem the tide from the source in addition to a mopping up operation downstream.
Adequate funding for drugs, reagents and materials, as well as an efficient good ...

Having worked in the TB control program in Nigeria for many years, my experience is similar to what Jean Baptiste Mulongo is reporting from the DRC.
Some patients on treatment have been found to stop treatment on account of inability to pay for some "hidden" costs even though TB treatment is officially free of charge. These hidden costs are sometimes justified by those demanding them for so many reasons e.g stock out of program drugs and reagents and materials so the hospital has to source them from the open market to continue treatment until their stock is replenished.

There are several other reasons for charging patients including under the table demands from some hospital staff which forces some patients to stop treatment especially after they have taken treatment for some time, have probably converted to sputum smear negative and are feeling better. As we know this is a veritable recipe for the development of drug resistance TB.
I have always argued that the fight against MDRTB should begin upstream by trying to stem the tide from the source in addition to a mopping up operation downstream.
Adequate funding for drugs, reagents and materials, as well as an efficient good logistic management system plus a good case holding/treatment adherence is what is required. How to handle the issue of financial demands from underpaid and under-motivated staff is a long term effort that is sometimes very frustrating in this environment

Ike

Je Suis d'accord Joseph avec vos idées , il faudra des interventionss de financements de nature à couvrir les besoins de patients réellement pour adhérer au traitement .Même dans les villages ou les populations sont plus pauvres ,n'ayant aucune subvention des autorités ,si on agit pas vite on pourra toujours conaître des problemes de manque d'adhérence , merci vraiment de votre expériences au nigéria ;

I think that this is a common scenario in many countries and in many clinics. In Vietnam, for example, some physicians ask for money for ARVs that are free through PEPFAR programs. I've seen patients that have been paying $50 USD per month for years when the drugs should be free. Another example are patients that are not referred to the TB program for their free TB therapy and instead are asked to pay for 'private therapy' from the HIV clinic. But I don't think that this is unique to the TB program or HIV program. In Vietnam, it is commonplace to give money to your doctor ('envelope' or tip) in order to get good or even appropriate care. Changing this practice will be difficult, I think, because it is part of the larger culture of medical care and other service-related industries...but I think higher wages for the physicians in public clinics is a good start. Thanks for the interesting post.

Hi All,

Thanks Ike, Jean Baptiste and Todd for sharing your experience with hidden fees and associated cost to TB treatment. As noted this is not a TB treatment-only issue. Funding is one obvious root cause (with underpaid and overworked health personnel for example as Ike commented) and transportation cost issues is outlined in the Guidelines for the programmatic management of drug-resistant tuberculosis, 2006, Stop TB Partnership http://www.ghdonline.org/drtb/resource/a-dots-plus-handbook-guide-to-the-community-b/ but also in ARV programs (http://www.ghdonline.org/adherence/resource/transportation-costs-impede-sustained-adherence-an/ for example).

Jean Baptiste, pour te répondre directement, on nous a informé qu’il est conseillé aux personnels de santé et aux patients atteints de la tuberculose (c.-à-d. diagnostiqués) qui sont mis face a ces pratiques de coûts cachés/associés au traitement en RDC de contacter directement le Programme National de lutte contre la Tuberculose. Tous les contacts (noms, emails, etc.) sont disponibles sur internet: http://pntrdc.canalblog.com/archives/qui_sommes_nous__/index.html J’imagine que cela n’est pas chose facile mais autant essayer tant que possible.

And now in English:
In the case of TB treatment in the DRC, colleagues at the national TB programme recommend that health personnel who see ...

Hi All,

Thanks Ike, Jean Baptiste and Todd for sharing your experience with hidden fees and associated cost to TB treatment. As noted this is not a TB treatment-only issue. Funding is one obvious root cause (with underpaid and overworked health personnel for example as Ike commented) and transportation cost issues is outlined in the Guidelines for the programmatic management of drug-resistant tuberculosis, 2006, Stop TB Partnership http://www.ghdonline.org/drtb/resource/a-dots-plus-handbook-guide-to-the-community-b/ but also in ARV programs (http://www.ghdonline.org/adherence/resource/transportation-costs-impede-sustained-adherence-an/ for example).

Jean Baptiste, pour te répondre directement, on nous a informé qu’il est conseillé aux personnels de santé et aux patients atteints de la tuberculose (c.-à-d. diagnostiqués) qui sont mis face a ces pratiques de coûts cachés/associés au traitement en RDC de contacter directement le Programme National de lutte contre la Tuberculose. Tous les contacts (noms, emails, etc.) sont disponibles sur internet: http://pntrdc.canalblog.com/archives/qui_sommes_nous__/index.html J’imagine que cela n’est pas chose facile mais autant essayer tant que possible.

And now in English:
In the case of TB treatment in the DRC, colleagues at the national TB programme recommend that health personnel who see this happening and patients who are diagnosed with TB and encounter issues of fees contact them directly. Though I can imagine this is not straightforward or easy by any means for health workers and people who are sick, destitute and in light of what others may think… this is at least one action that can be taken and hopefully people at the programme can help. Contact information for the national TB programme in DRC is available here: http://pntrdc.canalblog.com/archives/qui_sommes_nous__/index.html and I’ve also invited them to join this community.

Last but not least, a 2006 report on « Civil Society Perspectives on TB Policy in Bangladesh, Brazil, Nigeria, Tanzania, and Thailand » by the Open Society Institute provides some additional insights on this (report available full text in PDF at this link: http://www.soros.org/initiatives/health/focus/phw/articles_publications/publications/civilsociety_20061101/a_compilation_20061030.pdf):
- Loss of revenue (including in food production) associated with travel and waiting in line for care: In Nigeria for example some patients travel 40 km each day to receive treatment while another example comes from Tanzania where patients in some regions spend 1-6 hours per day in a clinic waiting for their medication.
- In some areas in Brazil, nutritional supplements and travel vouchers are available to TB patients as “incentives” along with supplementary medical services.

Additional thoughts are welcomed! Merci