TB Health Systems Research Prof Richard Coker

1. NTPs University of Public Health, Yangon TB Health Systems ResearchProf Richard Coker 1-2 August 2013

4. MDRTB epidemic in New York City, 1989-93 • Overcrowding • Homelessness • Criminal justice • HIV • Unemployment • Financial probs • Dysfunctional HS

5. Cost of case management. Samara, Russia Costs are spread across a number of years starting from treatment and shifting to managing chronic and social conditions Costs are driven by hospitalisation, both for BK+ and BK- cases.

6. Bed days in all TB facilities & TB beds (r= 0.99; P<0.0001)

7. Seasonality of admission and discharge Hospitals admit more patients in the cold seasons and discharge patients in spring and in summer months. The unusual prevailing discharge in Decembers is related to the retrospective payment system

8. The External Context Economic Political Levers Intermediate goals Goals Financing Equity (access and coverage) Health Organisational arrangements Choice Financial risk protection Resource allocation Efficiency Consumer satisfaction Provision Effectiveness Socio-demographic Technological

9. Context (C) Output (O),completion of treatment courses Input (I) e.g. smear positive cases of TB Mechanism (M),e.g. visiting nurses, CCT, other incentives Regularity (R)e.g. patient adherence to treatment (i.e. DOT component of DOTS) Coker et al. Int J Health Plann Mgmt 2004

10. Overall project design

11. Situational Analysis • Study will commence with initial situational analysis • Characterize health system, programs and other relevant environmental factors in both country settings • Provide common grounding framework and input to all three study components with an emphasis on understanding incentives at patient, community and health system level

12. NTPs University of Public Health, Yangon Gender dimensions of TB susceptibility, detection, and outcomes TB Control in Myanmar & Yunnan Province, China

13. Background “ TB is certainly a gender-biased, and is probably a sex-biased, infection…there is a need for such differences to be incorporated into models for TB control and forecasting “ (Rhines 2013: 106)

14. Background male:female ratios for newly notified TB (high-burden countries , 2011) (WHO 2012)

15. Background • Genuine differences in infection rates? • Artefact of reporting?

16. Research Design “ Biological mechanisms may actually account for a significant part of the difference between male and female susceptibility to TB “ Possible role for hormones, sex-related genetic background / genetic regulations, metabolism, anatomy of upper airway / respiratory tract (Neyrolleset al 2009: 1)

17. Research Design “ You see, only bad women have this disease. . . . Those who drink, smoke, and have illicit relations with men. . . Community needs to boycott them completely as a form of punishment for their doing. “ (Basu Khan 2011: 8)

18. Research Design

19. Research Design: RQ’s RQ1 What differences are observed in the recorded occurrence of TB infection among men and women (disaggregated by age) in the study settings? Do these differences vary among the wider population and the pre-identified “at risk groups”?

20. Research Design: RQ’s RQ2 • Do the gender roles and relations dominant in the study settings differentiate men’s and women’s risks of exposure to, and potentially of transmission of, TB (disaggregated by age and attendant to pre-identified risk groups)?

21. Research Design: RQ’s RQ3 Do the gender roles and relations dominant in the study settings differentiate men’s and women’s ability to access effective diagnostics and sustained treatment for TB (disaggregated by age and attendant to pre-identified risk groups)?

22. Research Design: RQ’s RQ4 Is social stigma of TB gender-differentiated in the study settings? What effects does stigma have for men’s and women’s ability to access and maintain effective TB treatment?

23. Research Design: RQ’s RQ5 • How is gender acknowledged and operationalisedin existing education and outreach programmes intended to prevent and / or encourage treatment for TB infection?

24. Research Design • Analysis at patient, community, healthcare provider and health system levels • Routine secondary data • Carefully designed micro-level survey • Detailed field study • Two study rounds: 2013/4 and 2015, 6 to 8 weeks

25. Research Design • Survey module within cohort study • i) Household demographics and individual characteristics • ii) Perceptions and experiences of access to, and utilisation of, healthcare • iii) Direct and / or indirect experiences of TB symptoms / infection / testing / • diagnosis / treatment / and out-reach programmes • iv) Perceptions of the causes of disease (including TB and HIV) and the types of • people perceived as most at risk • Attitudes about wider gender roles and relations

26. Research Design • Qualitative narrative analysis of individual attitudes and social norms regarding TB • Organised around primary data from semi-structured interviews (n = 40), informal group discussions (n = 10), and participant observation in a variety of key settings

27. NTPs University of Public Health, Yangon Economic EvaluatioN

28. Background • Economic evaluation is important for resource allocation decisions • However, very little economic evaluation of MDR-TB treatment • WHO GRADE evidence on economic evaluation of MDR-TB :“extremely low” • Fitzpatrick and Floyd(2010) systematic review : only 4 relevant/admissible studies • Different country settings / program models /timeframes/costs (Estonia, Peru, Russia & the Philippines) • Existing cases/ extrapolation to others suggests that treatment programs can generally be cost-effective • Cost per DALY estimates $143 - $745 in 2005 USD • Larger issues: • Need to consider interactions between TB, MDR-TB and HIV transmission, which affects outcome/cost dimensions over sustained period of time • The role of transmission (elimination, containment, mitigation, over what period?)

29. Understanding costs • Country-level data collection • Primary data collection • Nested cohort study within case-control study for outcomes and service utilization • Secondary data collection • Expenditure records, interviews with staff and patients, project records and databases, and the GLC secretariat. • Literature / assumptions where needed

30. Proposed Approach I: Costs and Outcomes Measurement for Nested Cohort Descriptive analysis of cost and outcome dynamics over the study period • Outcomes for individual patients • Conversion • Cure • Default • TB and TB-related death rates • HIV-related death rates • Costs • Individual utilization • Drugs • Hospital stays • Outpatient services • Laboratory/diagnostic tests • Nutritional/livelihood support • Others • Specific to program • Program management / administration • Training and technical assistance costs • Vehicles/equipment/ facilities • Advocacy • Others

31. Proposed Approach II: Economic Evaluation • Parameterize and calibrate an already published DSTB-MDRTB-HIV model to match existing data or best possible estimates in pre-program period. • Model employs a systems dynamics methodology to account for interacting variables, interconnected feedback loops involving time delays and non-linear relationships • Explicitly defines states of prevention, detection, treatment • Project incidence, cure and death rates and DALYS forward for study horizon for treatment population to generate a base case of “no program” • Compute cost per death averted/DALY estimates for the program relative to “no program” • Conduct uncertainty analysis

32. Example of model subsystem MDR TB Transmission

33. Proposed Approach III: Scenario Analysis Questions to be answered could include • What is the most effective way to allocate a set amount of funding? • Which % allocation(s) can generate the most deaths averted? • What is the marginal impact of additional funding? • How does the maximum potential level of deaths averted vary as the total amount of funding increases?

34. NTPs University of Public Health, Yangon Risk factors for MDR TB in Myanmar: A case-control study

35. Background • Urban residence • Frequent travellers • Younger age • Lack of a sewage system in the home • HIV status • Lung cavities WHO estimates 9,000 MDR-TB cases occur each year, with 1,200 receiving treatment in 2012. • Recent publications have identified several risk factors for MDR TB in high-risk countries including: • Previous TB treatment • Irregular treatment • Female sex • Non-permanent residents • Urban migration • Alcoholism • Smoking

36. Background A recent case-control study in China showed MDR-TB was independently associated with similar risk factors including retreatment for TB, however it also suggested other factors including: • Beijing genotype • Symptoms lasting >3 months before first evaluation at the hospital • lack of health insurance A cross sectional study in Myanmar (2002) showed statistically significant increased odds of MDR TB among previously treated patients Cases also tended to be male and in younger age-groups, although these associations were not statistically significant

37. Research Questions • What factors are associated with MDR-TB infection in patients previously treated for TB? • What factors are associated with MDR-TB infection in patients never before treated for TB? • Are risk factors disproportionately distributed between men and women?

38. Sampling Approach Study sites: - Clinics in and around Yangon Cases and controls identified through the NTP: • Cases with MDRTB (previously treated for TB) • Cases with MDRTB (not previously treated) • Controls : drug sensitive TB cases • Randomly selected from database? • Or time-matched cases e.g. presenting at the clinic in the same week?

39. Sampling Approach 9,000 new MDR-TB Cases 1,200 MDR-TB Cases On Treatment 400 MDR-TB Cases presenting in and around Yangon Not previously treated MDR-TB Cases Previously treated MDR-TB Cases Drug Sensitive Controls Non-TB Controls ? *Data from WHO, 2012. NTP data to inform this?

40. Sampling Approach Recruited cases and controls will be administered a questionnaire to collect socio-economic and epidemiological variables - A subset of cases and controls will be followed up prospectively to collect costing data Logistic regression analysis will then be carried out to compare new MDR TB case-patients, previously treated MDR TB case-patients, and non-TB controls to identify factors associated with MDR TB.

41. Additional Analysis? Samples will be saved on both host and pathogens to be typed by the Genome Institute in Singapore. Would allow investigation of: • Genotype clustering • Virulence factors • Host susceptibility

42. Discussion