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Comparison of two cash transfer strategies to prevent catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries: An economic modelling study.

ABSTRACT: Illness-related costs for patients with tuberculosis (TB) ?20% of pre-illness annual household income predict adverse treatment outcomes and have been termed "catastrophic." Social protection initiatives, including cash transfers, are endorsed to help prevent catastrophic costs. With this aim, cash transfers may either be provided to defray TB-related costs of households with a confirmed TB diagnosis (termed a "TB-specific" approach); or to increase income of households with high TB risk to strengthen their economic resilience (termed a "TB-sensitive" approach). The impact of cash transfers provided with each of these approaches might vary. We undertook an economic modelling study from the patient perspective to compare the potential of these 2 cash transfer approaches to prevent catastrophic costs.Model inputs for 7 low- and middle-income countries (Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen) were retrieved by literature review and included countries' mean patient TB-related costs, mean household income, mean cash transfers, and estimated TB-specific and TB-sensitive target populations. Analyses were completed for drug-susceptible (DS) TB-related costs in all 7 out of 7 countries, and additionally for drug-resistant (DR) TB-related costs in 1 of the 7 countries with available data. All cost data were reported in 2013 international dollars ($). The target population for TB-specific cash transfers was poor households with a confirmed TB diagnosis, and for TB-sensitive cash transfers was poor households already targeted by countries' established poverty-reduction cash transfer programme. Cash transfers offered in countries, unrelated to TB, ranged from $217 to $1,091/year/household. Before cash transfers, DS TB-related costs were catastrophic in 6 out of 7 countries. If cash transfers were provided with a TB-specific approach, alone they would be insufficient to prevent DS TB catastrophic costs in 4 out of 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $3.8 million (95% CI: $3.8 million-$3.8 million) and $75 million (95% CI: $50 million-$100 million) per country. If instead cash transfers were provided with a TB-sensitive approach, alone they would be insufficient to prevent DS TB-related catastrophic costs in any of the 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $298 million (95% CI: $219 million-$378 million) and $165,367 million (95% CI: $134,085 million-$196,425 million) per country. DR TB-related costs were catastrophic before and after TB-specific or TB-sensitive cash transfers in 1 out of 1 countries. Sensitivity analyses showed our findings to be robust to imputation of missing TB-related cost components, and use of 10% or 30% instead of 20% as the threshold for measuring catastrophic costs. Key limitations were using national average data and not considering other health and social benefits of cash transfers.A TB-sensitive cash transfer approach to increase all poor households' income may have broad benefits by reducing poverty, but is unlikely to be as effective or affordable for preventing TB catastrophic costs as a TB-specific cash transfer approach to defray TB-related costs only in poor households with a confirmed TB diagnosis. Preventing DR TB-related catastrophic costs will require considerable additional investment whether a TB-sensitive or a TB-specific cash transfer approach is used.

SUBMITTER: Rudgard WE

PROVIDER: S-EPMC5675360 | biostudies-other | 2017 Nov

REPOSITORIES: biostudies-other

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Comparison of two cash transfer strategies to prevent catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries: An economic modelling study.

Rudgard William E WE Evans Carlton A CA Sweeney Sedona S Wingfield Tom T Lönnroth Knut K Barreira Draurio D Boccia Delia D

PLoS medicine 20171107 11

<h4>Background</h4>Illness-related costs for patients with tuberculosis (TB) ≥20% of pre-illness annual household income predict adverse treatment outcomes and have been termed "catastrophic." Social protection initiatives, including cash transfers, are endorsed to help prevent catastrophic costs. With this aim, cash transfers may either be provided to defray TB-related costs of households with a confirmed TB diagnosis (termed a "TB-specific" approach); or to increase income of households with h ...[more]

PMID: 29112693

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Project description:BackgroundThere are limited nationally representative studies globally in the post-2015 END tuberculosis (TB) era regarding wealth related inequity in the distribution of catastrophic costs due to TB care. Under the Chinese national tuberculosis programme setting, we aimed to assess extent of equity in distribution of total TB care costs (pre-treatment, treatment and overall) and costs as a proportion of annual household income (AHI), and describe and compare equity in distribution of catastrophic costs (pre-treatment, treatment and overall) across population sub-groups.MethodsAnalytical cross-sectional study using data from national TB patient cost survey carried out in 22 counties from six provinces in China in 2017. Drug-susceptible pulmonary TB registered under programme, who had received at least 2 weeks of intensive phase therapy were included. Equity was depicted using concentration curves and concentration indices were compared using dominance test.ResultsOf 1147 patients, the median cost of pre-treatment, treatment and overall care, were USD 283.5, USD 413.1 and USD 965.5, respectively. Richer quintiles incurred significantly higher pre-treatment and treatment costs compared to poorer quintiles. The distribution of costs as a proportion of AHI and catastrophic costs were significantly pro-poor overall as well as during pre-treatment and treatment phase. All the concentration curves for catastrophic costs (due to pre-treatment, treatment and overall care) stratified by region (east, middle and west), area of residence (urban, rural) and type of insurance (new rural co-operative medical system [NCMS], non-NCMS) also exhibited a pro-poor pattern with statistically significant (P < 0.01) concentration indices. The pro-poor distribution of the catastrophic costs due to TB treatment was significantly more inequitable among rural, compared to urban patients, and NCMS compared to non-NCMS beneficiaries.ConclusionsThere is inequity in the distribution of catastrophic costs due to TB care. Universal health coverage, social protection strategies complemented by quality TB care is vital to reduce inequitable distribution of catastrophic costs due to TB care in China.

Project description:BACKGROUND:As well as imposing an economic burden on affected households, the high costs related to tuberculosis (TB) can create access and adherence barriers. This highlights the particular urgency of achieving one of the End TB Strategy's targets: that no TB-affected households have to face catastrophic costs by 2020. In Indonesia, as elsewhere, there is also an emerging need to provide social protection by implementing universal health coverage (UHC). We therefore assessed the incidence of catastrophic total costs due to TB, and their determinants since the implementation of UHC. METHODS:We interviewed adult TB and multidrug-resistant TB (MDR-TB) patients in urban, suburban and rural areas of Indonesia who had been treated for at least one month or had finished treatment no more than one month earlier. Following the WHO recommendation, we assessed the incidence of catastrophic total costs due to TB. We also analyzed the sensitivity of incidence relative to several thresholds, and measured differences between poor and non-poor households in the incidence of catastrophic costs. Generalized linear mixed-model analysis was used to identify determinants of the catastrophic total costs. RESULTS:We analyzed 282 TB and 64 MDR-TB patients. For TB-related services, the median (interquartile range) of total costs incurred by households was 133 USD (55-576); for MDR-TB-related services, it was 2804 USD (1008-4325). The incidence of catastrophic total costs in all TB-affected households was 36% (43% in poor households and 25% in non-poor households). For MDR-TB-affected households, the incidence was 83% (83% and 83%). In TB-affected households, the determinants of catastrophic total costs were poor households (adjusted odds ratio [aOR]?=?3.7, 95% confidence interval [CI]: 1.7-7.8); being a breadwinner (aOR?=?2.9, 95% CI: 1.3-6.6); job loss (aOR?=?21.2; 95% CI: 8.3-53.9); and previous TB treatment (aOR?=?2.9; 95% CI: 1.4-6.1). In MDR-TB-affected households, having an income-earning job before diagnosis was the only determinant of catastrophic total costs (aOR?=?8.7; 95% CI: 1.8-41.7). CONCLUSIONS:Despite the implementation of UHC, TB-affected households still risk catastrophic total costs and further impoverishment. As well as ensuring access to healthcare, a cost-mitigation policy and additional financial protection should be provided to protect the poor and relieve income losses.

Project description:BackgroundThe World Health Organization's End Tuberculosis Strategy states that no tuberculosis (TB)-affected households should endure catastrophic costs due to TB. To achieve this target, it is essential to provide adequate social protection. As only a few studies in many countries have evaluated social-protection programs to determine whether the target is being reached, we assessed the effect of financial support on reducing the incidence of catastrophic costs due to TB in Indonesia.MethodsFrom July to September 2016, we interviewed adult patients receiving treatment for TB in 19 primary health centres in urban, sub-urban and rural area of Indonesia, and those receiving multidrug-resistant (MDR) TB treatment in an Indonesian national referral hospital. Based on the needs assessment, we developed eight scenarios for financial support. We assessed the effect of each simulated scenario by measuring reductions in the incidence of catastrophic costs.ResultsWe analysed data of 282 TB and 64 MDR-TB patients. The incidences of catastrophic costs in affected households were 36 and 83%, respectively. Patients' primary needs for social protection were financial support to cover costs related to income loss, transportation, and food supplements. The optimum scenario, in which financial support would be provided for these three items, would reduce the respective incidences of catastrophic costs in TB and MDR-TB-affected households to 11 and 23%. The patients experiencing catastrophic costs in this scenario would, however, have to pay high remaining costs (median of USD 910; [interquartile range (IQR) 662] in the TB group, and USD 2613; [IQR 3442] in the MDR-TB group).ConclusionsIndonesia's current level of social protection is not sufficient to mitigate the socioeconomic impact of TB. Financial support for income loss, transportation costs, and food-supplement costs will substantially reduce the incidence of catastrophic costs, but financial support alone will not be sufficient to achieve the target of 0% TB-affected households facing catastrophic costs. This would require innovative social-protection policies and higher levels of domestic and external funding.

Project description:IntroductionInfertility, a condition of the reproductive system, affects millions of individuals and couples worldwide. Despite infertility treatment's existence, it is largely unavailable and inaccessible in low/middle-income countries (LMICs) due to the prohibitive costs compounded by an absence of financing. Previous systematic reviews have shown that there is scanty information in LMICs on out-of-pocket (OOP) payments for infertility treatment. This protocol outlines the methodological approach and analytical process to appraise the extent of economic burden due to payments for infertility care services in LMICs.Method and analysisUsing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach, we will primarily search for articles indexed in PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit and PsycINFO databases. Grey literature from relevant organisations' virtual libraries shall also be searched. Backward and forward searches on the articles selected will also be done. Quantitative studies on infertility treatment costs from LMICs across the world regions within the last 20 years will be considered. The primary outcome of interest shall include OOP payments, catastrophic health expenditure and direct costs for infertility services. Conversely, informal payments and indirect costs related to infertility treatments shall be considered as secondary outcomes. Integrated quality Criteria for Review Of Multiple Study designs will be used to assess the quality of the studies included in the review. Meta-analysis shall be considered if sufficient studies identified are homogenous in characteristics. Also, the review shall analyse the average cost of infertility treatment against the respective countries' economic indicators like gross domestic product per capita if data permit.Ethics and disseminationResearch and ethics approval will not be required given this will be a review of published articles on the subject. The findings shall be disseminated through publication in a peer-reviewed journal and presentation to the WHO and its partners.Prospero registration numberCRD42020199312.

Project description:BackgroundStunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries.MethodsThis multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting.FindingsAcross 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied.InterpretationChildhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.

Project description:Spatio - temporal modelling of malaria has proven to be a valuable tool for forecasting as well as control and elimination activities. This has been triggered by an increasing availability of spatially indexed data, enabling not only the characterisation of malaria at macrospatial and microspatial levels but also the development of geospatial techniques and tools that enable health policy planners to use these available data more effectively. However, there has been little synthesis regarding the variety of spatio - temporal approaches employed, covariates employed and 'best practice' type recommendations to guide future modelling decisions. This review will seek to summarise available evidence on the current state of spatio - temporal modelling approaches that have been employed in malaria modelling in low and middle-income countries within malaria transmission limits, so as to guide future modelling decisions.A comprehensive search for articles published from January 1968 to April 2018 will be conducted using of the following electronic databases: PubMed, Web of Science, JSTOR, Cochrane CENTRAL via Wiley, Academic Search Complete via EBSCOhost, MasterFILE Premier via EBSCOhost, CINAHL via EBSCOhost, MEDLINE via EBSCOhost and Google Scholar. Relevant grey literature sources such as unpublished reports, conference proceedings and dissertations will also be incorporated in the search. Two reviewers will independently conduct the title screening, abstract screening and, thereafter, a full-text review of all potentially eligible articles. Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines will be used as the standard reporting format. A qualitative thematic analysis will be used to group and evaluate selected studies around their aim, spatio - temporal methodology employed, covariates used and model validation techniques.Ethical approval is not applicable to this study. The results will be disseminated through a peer-reviewed journal and presented in conferences related to malaria and spatial epidemiology.CRD42017076427.

Project description:BackgroundBetween 2012 and 2016, development assistance for HIV/AIDS decreased by 20·0%; domestic financing is therefore critical to sustaining the response to HIV/AIDS. To understand whether domestic resources could fill the financing gaps created by declines in development assistance, we aimed to track spending on HIV/AIDS and estimated the potential for governments to devote additional domestic funds to HIV/AIDS.MethodsWe extracted 8589 datapoints reporting spending on HIV/AIDS. We used spatiotemporal Gaussian process regression to estimate a complete time series of spending by domestic sources (government, prepaid private, and out-of-pocket) and spending category (prevention, and care and treatment) from 2000 to 2016 for 137 low-income and middle-income countries (LMICs). Development assistance data for HIV/AIDS were from Financing Global Health 2018, and HIV/AIDS prevalence, incidence, and mortality were from the Global Burden of Disease study 2017. We used stochastic frontier analysis to estimate potential additional government spending on HIV/AIDS, which was conditional on the current government health budget and other finance, economic, and contextual factors associated with HIV/AIDS spending. All spending estimates were reported in 2018 US$.FindingsBetween 2000 and 2016, total spending on HIV/AIDS in LMICs increased from $4·0 billion (95% uncertainty interval 2·9-6·0) to $19·9 billion (15·8-26·3), spending on HIV/AIDS prevention increased from $596 million (258 million to 1·3 billion) to $3·0 billion (1·5-5·8), and spending on HIV/AIDS care and treatment increased from $1·1 billion (458·1 million to 2·2 billion) to $7·2 billion (4·3-11·8). Over this time period, the share of resources sourced from development assistance increased from 33·2% (21·3-45·0) to 46·0% (34·2-57·0). Care and treatment spending per year on antiretroviral therapy varied across countries, with an IQR of $284-2915. An additional $12·1 billion (8·4-17·5) globally could be mobilised by governments of LMICs to finance the response to HIV/AIDS. Most of these potential resources are concentrated in ten middle-income countries (Argentina, China, Colombia, India, Indonesia, Mexico, Nigeria, Russia, South Africa, and Vietnam).InterpretationSome governments could mobilise more domestic resources to fight HIV/AIDS, which could free up additional development assistance for many countries without this ability, including many low-income, high-prevalence countries. However, a large gap exists between available financing and the funding needed to achieve global HIV/AIDS goals, and sustained and coordinated effort across international and domestic development partners is required to end AIDS by 2030.FundingThe Bill & Melinda Gates Foundation.

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Comparison of two cash transfer strategies to prevent catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries: An economic modelling study.

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Comparison of two cash transfer strategies to prevent catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries: An economic modelling study.

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