Highlights of Satellite Symposium on TB & Poverty,11-12 October 2002, Montreal Canada <<<

	The objectives of the meeting included: 1. Provision of an opportunity for exchange between researchers and TB control experts regarding poverty-related issues in order to facilitate closer cooperation between poverty research and DOTS expansion. 2. Initiation of the formulation of new strategies, supported by solid evidence for greater equity in DOTS Expansion, for greater access and better quality care for the poor.

	Here are excerpts of the symposium covering some of the issues that were discussed Tuberculosis, poverty and inequity Christy L. Hanson World Bank, Washington TB & Poverty in context of global TB control Holger Sawert World Health Organization Country Perspective- Pakistan Public-Private Mix, M.A. Khan Group Works Group 1 : Prioritizing pro-poor approaches within the DOTS expansion agenda Group 2 : Networking for poverty related research across key themes Group 3 : How to involve the poor Mainstreaming a Poverty Focus within the Stop-TB Partnership

	Tuberculosis, poverty and inequity Christy L. Hanson World Bank, Washington There is an urgent need to strengthen implementation of DOTS strategy to ensure the inclusion of pro-poor approaches Historically, tuberculosis (TB) has been associated with economic hardship, urbanization and other socio-economic factors. The evidence suggests that the prevalence of tuberculosis is disproportionately high among poor countries and among disadvantaged groups within countries. A recent study by World Bank entitled ‘Voices of the poor’ highlighted the multi-dimensional nature of poverty, expanding the definition of poverty beyond the traditional aspects of low income and consumption. The study reinforced the notion that ill health is an important attribute of poverty and is feared by the poor. From the standpoint of equity, the global TB epidemic is a cause for concern. TB patients are certainly amongst those with the poorest health, TB burden is disproportionately high among poor countries and deaths due to TB are avoidable. Currently the WHO recommended strategy for detecting and curing TB; DOTS is available only to around half of the world’s population, this represents an unequal access to quality care. Evaluating the association between tuberculosis and poverty requires considerations from social, community and individual perspectives. At the societal level, one might consider how the burden of tuberculosis weighs on the relatively rich as compared to poor countries. Of the 22 countries that account for 80% of world’s TB burden 78% have an annual GNP per capita of less than US $ 760; the criterion used by the World Bank for classification as a low income country. None of the highest TB burden countries are high-income countries. Historical reviews have demonstrated that increased TB incidence may be associated with constrained macroeconomic conditions and periods of economic transition. In Switzerland and the Netherlands, tuberculosis mortality increased during the Second World War, more recently, a dramatic increase in tuberculosis incidence has been seen in the nations of former Soviet Union- a possible reflection of economic and social transition. Where HIV is fuelling the TB epidemic, such as in Africa, it is also interesting to consider the association between poverty and HIV/AIDS as this is likely to influence the relationship between poverty and TB in the years to come. The literature has suggested an increased risk of HIV transmission associated with various facets of poverty such as low levels of education, lack of access to information, and limited ability to pay for medical advice and condoms. The evidence suggests that the impoverishing effects of TB are most damaging to those who were relatively poor or marginalized in some way before being infected with TB. TB may push the income impoverished into poverty, the food impoverished into a state of malnutrition and wasting, and women into isolation. One of the core principles of DOTS strategy is the availability of quality, free TB drugs for all smear-positive pulmonary patients through public health network. The DOTS policy therefore promotes equity enhancement. The policy of free TB drugs is meant to remove a financial barrier to accessing and completing TB treatment. To better reach the poor with TB services and to support their treatment completion, it is important to understand how the poor demand TB care so as to enable a response that targets both societal and systemic barriers to care. Studies are going on in order to evaluate the social and behavioral influences that impact a patient’s movement through the diagnostic and treatment process. New efforts to document and assess the effectiveness of incentive schemes in DOTS delivery suggest that these approaches might be a means to improve access and utilization of TB services by poor patients. Incentives are being used in many programs worldwide to enable and stimulate participation by patients and providers in DOTS based care. Examples include provision of monthly food packages and monetary and non-monetary incentives to community based providers. There is an urgent need to strengthen implementation of DOTS strategy to ensure the inclusion of pro-poor approaches such as inclusion of smear-negative and extra pulmonary patients among the subsidized prioritized activities, specify and monitor equity objectives and targets, decrease diagnostic delay and target health promotion activities to poor and disadvantaged areas. An evaluation of the impact and cost-effectiveness of existing pro-poor approaches, building an evidence base and beginning systematic monitoring of the magnitude of TB burden amongst poor and performance of current DOTS programme in reaching the poor and supporting an operational research to identify and stimulate timely and affordable access to TB services are other possible next steps.
	TB and Poverty in the context of global TB control Holger Sawert, World Health Organization A well functioning health infrastructure is a pre-condition for DOTS success. There is no ambiguity about global TB control targets: 70% case detection and 85% cure rate by the year 2005. There has been a rapid DOTS expansion and by the end of year 2000, 148 countries were implementing DOTS. However we need to step up our efforts especially in the context of case detection. There seems to be no correlation between DOTS expansion and case detection. Increased coverage does not include case detection. Experience has demonstrated that cent percent coverage with DOTS does not lead to 70% case detection. Thus there is an issue of missing cases, which we are not reaching with our DOTS strategy. There is a school of thought, which believes that there are no missing cases- there is only a poor DOTS implementation. Countries with good DOTS programmes have high case detection rates (CDR) e.g. India has a CDR of 66%. They insist that there is a need to focus on quality DOTS services and additional strategies are only of minor importance. The second school of thought says that standard DOTS is really missing cases and we need additional strategies to reach CDR targets. These could include combined TB and HIV control strategies, community based approaches, public-private mix, incentive for enablers and finding new financing resources. The questions, which one needs to ask, are - Is there a pro-poor bias in our current approaches? Is there any evidence that targeting the poor will make a difference? Both TB and HIV thrive on poverty. Targeting the poor will definitely make a difference because core issue is one of access and in poor settings access is restricted. Several projects throughout African countries have shown that involving community workers in TB control can help. In these projects the goal was to improve access to TB care through decentralization. The results of the projects demonstrated that cure rates improved and cost effectiveness ratio was much favorable than service delivery at work place or clinic level. There was an increase in rate of successful TB treatment in districts where community was involved. The barriers in TB control include poverty and HIV related stigma. Private Practionners deliver poor TB control services. The issues involved here are those of access, time, travel costs, costs related to diagnosis and treatment, stigma and attitude of the service providers. There is only empirical evidence about role of incentives to enablers and initiative is on to document it. Currently there is a focus on primary health care with comprehensive geographical coverage. A well functioning health infrastructure is a pre-condition for DOTS success.
	Country Perspective- Pakistan Public-Private Mix, M.A. Khan Association for Social Development Pakistan Pakistan opts for public private mix for TB control Pakistan is a developing country, with four provinces and 140 million people. One third of its population lives below poverty line. The per capita health expenditure in the country is less than US $ 3 in a year. The country has a sub-optimal primary health care infrastructure. The country ranks 6^th among nations with a high TB burden. The TB prevalence in the country is more than 250/100,000. DOTS availability through public health sector is limited to about one third of the country. Many districts implementing DOTS are plagued with low case detection rate of less than 30%. A countrywide network of private sector care providers exists in the country. These include both not-for –profit and for-profit private care providers. However there is little regulation or governmental support for these centers. In fact a wide variation in the practices followed by doctors here, results in low cure rates. The managers of the National TB Programme Managers in the country had two options available to them: Either leave the private sector out or develop a partnership with it. The NTP managers opted for the later. Currently the policy and management issues are being discussed. However there is a consensus that private sector will be involved only in those districts where a good NTP is in place. NTP will support and supervise the services provided by private sector. It will provide logistics for free diagnosis and treatment of tuberculosis. NTP managers tend to learn by doing before expanding.

	Group 1 Prioritizing pro-poor approaches within the DOTS expansion agenda Rapporteur: Karen Bissell Currently DOTS programmes are not reaching all those with TB. There is an assumption that these missing cases are mostly poor and vulnerable. The linkages between poverty and TB may be inherent in most settings. However these concepts need to be converted into measurable and system related indicators. The group put forward following mid-term and long-term suggestions: Create a database of poverty and TB related literature. The messages about TB and poverty linkages and their impact on DOTS expansion need to be put forward in no uncertain terms. A communication strategy is developed to propagate these messages at all levels, from Stop TB partnership to local. Various working groups in Stop TB partnership are encouraged to incorporate poverty related considerations in their work. A set of research tools (which can be combined with existing processes) may be designed to further explore and document the TB and poverty linkages. Stop TB partners are encouraged to advocate and facilitate national and sub-national mobilization to demand quality care for the poor. A proposal to set up Stop TB partnership at national levels deserves to be given a serious consideration. DOTS strategy outcome indicators may be expanded to include poverty and strengthening of primary health care.

	Group 2 Networking for poverty related research across key themes The group addressed three issues, exploratory research; interventional research and organizational and networking strategies to charter the way forward. The group felt that certain key questions need to be answered within the diverse contexts: Does the DOTS reach the poor and which processes are most problematic or successful? If DOTS reached the poor would it make a difference? To what an extent voices of poor are heard in design and delivery of these services? How does our current knowledge of access and impact influences modification of DOTS services in problem areas. In the context of improving access to DOTS, how the access to laboratory and diagnostic process can be improved without compromising quality. What impact can communication and social mobilization make on increasing access and utilization of DOTS? A possible purpose of networking could be enabling south -south and south-north exchange to design pro-poor approaches for TB diagnosis, treatment and care in different contexts. The group felt that there was an urgent need to raise the profile of challenge within and outside the TB community. The exchange of methodologies and technical expertise available in different settings can benefit the programme. As a short-term measure web based exchange amongst partners can be expanded and an identifiable structure set up to maintain the momentum generated in the context of TB and poverty theme.

	Group 3 How to involve the poor Rapporteur: Dr. Vikas Inamdar The poor can be defined as marginalized or income poor or those who lack access to human rights. The involvement of poor in DOTS services can be enlisted through decentralization of services and active involvement of community in local affairs. The services of Non-Government-Organizations, self help groups (comprising of cured TB patients) and local institutions like village chief and religious institutions can prove to be highly beneficial. The involvement of poor could also be brought about through awareness and mobilization of community to demand health care services. Integration of health with other public welfare services and bringing diagnostic services closer to communities can also elicit participation by poor in availing the DOTS services.
	The report prepared by Dr. Dinesh Kumar, Director Health and Development Initiative India


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	Stop TB, fight poverty Satellite Symposium on TB and Poverty Montreal 11^th and 12^th October 2002 This Satellite Symposium which built on the World TB day 2002 theme: “Stop TB, fight poverty” took place immediately after the 33^rd IUATLB World Conference on Lung Health was jointly organized by the Stop TB Initiative and EQUI-TB Knowledge Programme, Liverpool School of Tropical Medicine.