Thailand - Stop TB Partnership

The hidden costs of treatment
It is true that we receive free diagnosis and treatment, but [TB] drugs are
very powerful, and they need to be taken with sufficient food. A majority of
us [patients] are from poor families and we have only one meal per day.
So sometimes we are forced to skip the drugs.
—TB patient, Dar es Salaam, Tanzania 40
Adhering to the six-month TB treatment regimen is a challenge, particularly for patients
who are malnourished, taking antiretroviral drugs, grappling with other illnesses, or poor.
Strict compliance with treatment requires a serious investment of patients’ time, energy, and
household resources. Reports from all five countries revealed that even though TB treatment
is free, patients are often confronted with significant “hidden costs,” including outlays for
diagnostic tests, transportation to health facilities, nutritional supplements (since patients
require an adequate diet to take their medications), and time away from work. In Tanzania,
patients from rural areas in particular may spend several hours traveling to and from health
facilities and one to six hours in the clinic waiting to receive medications—every day for
the first two months of treatment. Similarly, in Nigeria, research revealed that states in the
north, which are typically poorer, have far fewer TB centers available per capita, meaning
that patients have to travel much farther for treatment. For example, as of January 2005,
Zamfara State in the north had only 10 DOTS centers for a population of 3.6 million people,
while Ogun State in the south had 116 DOTS centers for 2.3 million people. 41 For many
patients, who also have to think about earning a livelihood and familial responsibilities,
traveling such a long distance for TB care is simply untenable.
Yet despite the clear connection between TB and socioeconomic factors, governments
continue to deal with the disease primarily as a public health problem rather than
as a broader development issue. TB is usually left to the “experts,” a small circle of medical
and health professionals working within or connected to the Ministry of Health. For
example, while maternal and child health, infant mortality, and HIV/AIDS are highlighted
in Thai poverty reduction schemes, TB is not mentioned. The Brazilian government has
long acknowledged that providing “incentives” such as nutritional supplements and transportation
subsidies to TB patients is necessary to ensure treatment adherence. Yet under
Brazil’s decentralized system, individual states and municipalities have the responsibility
to budget for the incentives, and thus their availability in practice varies greatly from state
to state and within states.
Patterns of TB prevalence and the crippling hidden costs of treatment may
help to explain why there has not been more civil society involvement around TB. People
living in poverty, women, and members of other vulnerable groups are not generally well
PUBLIC HEALTH WATCH MONITORING REPORTS 21