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Summary

Introduction:

There is a widespread notion that TB is disease of poverty. It would seem, therefore, that treating TB patients through the DOTS strategy will contribute services for the poor. In recent years, however, a number of investigators have been examining the extent to which DOTS reaches poor people within countries and finding that, in common with delivery of other health services, it is difficult to include poor even where DOTS is well established. In 2002 the Global Stop TB Partnership adopted the theme of Stop-TB, Fight Poverty. Under this theme a number of country programmes have begun to share their experiences of examining the extent to which they reach poor. As a consequence they are formulating policies and activities aimed at including more poor patients. In an era when TB case detection is a major challenge and when health providers are examining carefully how they can contribute to Millennium Development Goals, it is timely that the International Union Against TB and Lung Disease (IUATLD) provided a forum in which some of the globe’s country-level experiences could be shared. From a head-count mid-way through the symposium approximately 300 people attended and the following key themes emerged from the presentations and discussion.

Key Themes:

1. Costs incurred by patients prior to diagnosis are a major issue, even when public health services consultations and diagnostic tests are free. It was questioned to what extent TB is a special case in this regard, but there is a consensus that onward action by health service providers to look at ways in which they can reduce the cost, complexity and length of care-seeking pathways is important.
    

2. The TB control community must look to health systems in general and beyond in addressing access to TB services. It is important, however, that TB control programmes do not abrogate responsibility for providing for the poor by saying that it is not their core business, but the business of health systems more widely.
    

3. Well-funded public health systems are central to any capacity to provide good quality TB care to poor patients. There was agreement that such systems are necessary but not sufficient in this regard.
    

4. Implementing a high quality TB programme may make a major first step in providing for the poor. It is important in this respect to consider the perspective from which quality is judged. If quality is judged solely on cure rates rather than from the perspective of poor patients, things can be distorted. It is important, for example, not to force a patient to choose between work or eating and DOTS supervision.
    

5. In some settings the targeting of services and resources may be more appropriate than overall changes in quality of DOTS provision (in contrast with point 4). Many caution however against targeting becoming a science in itself without actually making the difference required.
    

6. Examining TB control from a Poverty perspective reminds implementers that tend to look at figures and may miss the human face of TB. Unless these issues are brought on board in a coherent manner (e.g. through development of guidelines and policies on TB and Poverty), TB control will not move forward.

Christy Hanson (World Bank/WHO) and S Bertel Squire (UK) were Chairpersons of the Symposium. Tim Evans (WHO/Rockefeller foundation, Khandaker Rashedul Haque (Bangladesh), Gillian Mann (on behalf of Julia Kemp-Malawi), Qingyue Meng (China) and Bertha Nhlema (Malawi) made the presentations.

Report prepared by: S Bertel Squire (Symposium Co-ordinator)