New operational research finds TB patients diagnosed through active case finding suffer less financial costs

New research led by researchers from The International Union Against Tuberculosis and Lung Disease (The Union) South-East Asia Office has found that active case finding (ACF) among marginalised and vulnerable populations in India reduces the costs to the individual significantly during the diagnosis period of tuberculosis (TB), when compared to individuals detected through passive case finding (PCF). In PCF, patients with TB symptoms visit public health services on their own for diagnosis whereas in ACF, the health system reaches out to the community and systematically screens the population to find people with TB symptoms.  

The research findings published in Global Health Action journal outlines that patients incur significant direct medical, direct non-medical and indirect costs due to TB diagnosis. Measuring these costs during diagnosis is important because it is the most uncertain period during illness. Globally, the total cost due to TB care (diagnosis and treatment) was equivalent to 39 percent of the annual household income, and half of the total cost was incurred during diagnosis. These total costs become catastrophic to the household if they exceed 20% of the pre-TB annual household income.  

When compared with patients diagnosed through PCF, ACF patients among marginalised and vulnerable populations resulted in lower total costs and lower prevalence of catastrophic costs due to TB diagnoses. Adjusted analysis showed that patients detected through ACF had a 32 percent lower prevalence of catastrophic costs relative to PCF. However, ACF did not address the issue of intensity and inequity in distribution of catastrophic costs.  

The study, led by Dr Hemant Deepak Shewade, Senior Operational Research (OR) Fellow at The Union, is part of a series of studies exploring if The Union’s active case finding strategy under project Axshya (Axshya means ‘free of TB’) is effective in reducing i) TB diagnosis delays ii) costs due to TB diagnosis and iii) unfavourable TB treatment outcomes.  In 2016-17, as part of Project Axshya, operating in 285 districts spread across 19 states in India, trained community volunteers visited households in marginalised and vulnerable areas. They educated members of the household on TB and screened them for symptoms. People with symptoms were then referred to public health facilities for TB diagnosis and treatment. Project Axshya is funded by The Global Fund against AIDS, TB and Malaria.

The Centre for Operational Research of The Union supported project Axshya in the design, planning and implementation of the study. Dr Hemant Deepak Shewade is supported under the Global Operational Fellowship programme by The Department for International Development of The United Kingdom (DFID).

This is the first study from India that has looked at the effect of ACF among marginalised and vulnerable populations on costs incurred by patients due to TB diagnosis. The significant reduction in patient costs and prevalence of catastrophic costs supports the recommendation of the Revised National Tuberculosis Control Programme (RNTCP) in its national strategic plan to eliminate TB, 2017-25, regarding the implementation of ACF among clinically, socially and occupationally vulnerable populations over and above the existing PCF strategies.

However, there is a need to address the issue of inequity and intensity of catastrophic costs, irrespective of whether TB patients are identified by ACF or PCF. Hence, India needs to move towards Universal Health Coverage (UHC) and Social Protection (SP). UHC is expected to reduce the direct medical costs and SP is expected to protect against direct non-medical and indirect costs.

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