Addressing poverty in TB control

Addressing poverty in TB control: The Thailand experience
Bobby Ramakant – CNS

At the tuberculosis (TB) and poverty sub-working group meeting which was held recently in India (29-30 October 2010), the experience of Thailand in responding to TB particularly among those who were poor (or uninsured) was in the spotlight. The government of Thailand along with other partners has taken major steps to prevent, diagnose and treat TB, particularly among those people who are uninsured (or poor). The discussion around TB and poverty assumes further significance as just a week or more later, the 41st Union World Conference on Lung Health is slated to open in Berlin, Germany on the theme of "TB, HIV and Lung Health: from research and innovation to solutions."

The secretariat of the TB and Poverty sub-working group has now moved to the South-East Asia office of The International Union Against Tuberculosis and Lung Disease (The Union) located in India. It makes so much more sense for the secretariat to be in one of the most TB and poverty affected countries - India.

Thailand is one of the 22 high TB-burden countries. The case detection rate (CDR) in Thailand reached 72% in 2007 (2005 target set by the 1991 World Health Assembly was to achieve 70% CDR), and the treatment success rate improved to 77% in 2006 (2005 target was to achieve 85% treatment success rate). According to the Global Tuberculosis Control Report of WHO 2009, reasons why the treatment success rate is below the global target of 85% include high default and mortality rates, and incomplete reporting from care providers.

Those people who have latent TB infection or active TB disease, or are at an elevated risk of contracting TB are often the ones who are not able to access existing TB-related services.

"54% of the TB patients were daily wage workers who were earning between Thai Baht (THB) 150-250 (USD 5-8) per day, 24% were full-time workers, 14% unemployed and 8% of TB patients were students" said Dr Sirinapha Jittimanee, Public Health Officer, National TB Programme (NTP), Thailand. This study was published in the International Journal of Nursing Practice (2007).

In other words, 68% of TB patients in this Thai study were either unemployed (14%) or earning USD 5-8 per day as daily wage workers. According to the World Bank data, 2009 Gross National Income per capita in Thailand was USD 3760. It is evident that unemployed and those Thai people earning low daily wages were the ones dealing with majority of TB burden in Thailand. Clearly poor people are at an elevated risk of TB.

There are five key activities already taking place in Thailand to address poverty and mitigate its impact on TB control programmes. "Those who aren't insured to get health services in Thailand are eligible to benefit from these schemes" said Dr Sirinapha.

1. The Thai social welfare programme is available in all public hospitals. This is funded by the government of Thailand to provide treatment and meet transportation costs of the poor patients, including those with active TB disease.

2. In 2007, the government of Thailand initiated the Community Health Fund (CHF) which is managed by the National Health Security Office (NHSO). There are about 7,848 Local Administrative Organizations (LAO) covering the entire country. Each LAO has the CHF to support health activities in the community and controls local health resources. TB activities supported by the CHF includes financial incentives for the DOT observers and living monthly allowance of Thai Baht (THB) 500 for each of those patients who are unable to earn their living, or meet their transportation costs, or need the money for food. Few LAO also support the TB activities because the local TB programme team members aren’t familiar with the mechanism to request financial resources.

3. The 'Thailand Relief Foundation for TB Patients' provides small funding for projects mainly supporting poor TB patients. For example this Foundation has supported nutrition programmes and programmes aimed to provide transportation costs to TB patients. This is not funded by the government but donations are the source of funding for this foundation.

4. The country budget at TB Bureau in Thailand procures the anti-TB drugs (both first-line and second-line drugs) for uninsured TB patients nationwide. In this year 2010, 1,500 people received first-line anti-TB drugs under this programme, and the cost of THB 3,570,000 was met by the TB Bureau in Thailand. In the same year, 220 people received second-line anti-TB drugs and the cost of which THB 7,637,300 was also met by TB Bureau of Thailand. In 2011, it is projected that 2000 insured people will be seeking first-line anti-TB drugs in Thailand and the cost of THB 4,760,486 will be met by the TB Bureau. Also in 2011, it is estimated that 155 uninsured people will seek second-line anti-TB drugs and the cost of THB 5,347,000 will be met by the TB Bureau of Thailand.

5. The Global Fund to fight AIDS, TB and Malaria (GFATM) round-8 grant is also dedicated to mobilize political commitment for the government of Thailand's Community Health Fund (CHF) to secure TB funding at local level. This grant takes care of 2 or more food coupons for new TB patients (THB 200 or about 6-7 USD) during intensive and continuation phases of DOTS. It is also used to provide 16 food coupons to MDR-TB patients, and to provide the travel costs for children receiving isoniazid (INH) prophylaxis therapy (IPT) for preventing latent TB into becoming active TB disease. This grant is used to provide for emergency houses and travel costs for jail inmates as required when they are released before the treatment completion. This grant is used for capacity building activities of people living with HIV (PLHIV) for promoting access to TB care.

There are other issues too that are impediment to Thailand's response to TB control, particularly among poor people. TB programme staff has limited skills to approach existing local funding organizations or mobilize resources, says Dr Sirinapha. "Besides there is uncertainty of political commitment due to the 4 year term of elected political leaders and members" said Dr Sirinapha.

Dr Sirinapha also explained how the healthcare system in Thailand works. She said that there are two major stakeholders: 1) service provider, is the Ministry of Public Health, Thailand; and 2) service purchaser is the National Health Security Office (NHSO) which was established in 2003.

“A clear purchaser-provider relationship is established in order to make the examination, monitoring, and evaluation system more efficient” said Dr Sirinapha. “Decentralization is implemented at local level which allows local people to participate in local affairs” said Dr Sirinapha.

The Thai TB programme works closely with community based organizations (CBOs) of people living with HIV (PLHIV), and other non-governmental organizations (NGOs) like World Vision Foundation of Thailand, Raksthai Foundation, National Catholic Commission of Migration and Prisoners among others. (CNS)

Bobby Ramakant – CNS
(The author serves as the CNS Policy Adviser and Director of CNS Stop-TB Initiative. He received the World Health Organization (WHO) Director-General’s WNTD Award 2008. He writes extensively for Citizen News Service and can be contacted at: bobby@citizen-news.org, website: www.citizen-news.org )

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