Barriers to tuberculosis diagnosis and treatment in Zambia

Someone with untreated tuberculosis (TB) will infect up to 14 others over a year. TB programmes must lower barriers to care-seeking to reduce this spread. From patients’ perspectives, barriers include treatment costs and travel. Proposed reforms to TB programmes in sub-Saharan Africa, including decentralisation, must consider each country's context to prevent negative impacts on care-seeking and under-funded primary health care services.

TB treatment is a very cost-effective health intervention inthe developing world. Despite this, the disease kills almost two million adultseach year. Many patients can spot the symptoms of TB and see the need fortreatment, but socio-economic and cultural factors may prevent effective diseasecontrol.

In this study at the University of Zambia, interviews wereconducted with 202 patients in 1996. These interviews revealed three themesunderlying patient barriers to TB diagnosis:

• number of health care encounters and duration ofillness prior to diagnosis
• financial constraints and unrecognised patientcosts
• travel distances.

On average, patients have 6.7 health encounters over 63 daysbefore being referred for TB diagnosis at the centralised government ChestClinic. This period can involve self-treatment with ‘western’ or herbalremedies, or visits to traditional healers or private physicians. Even withinthe public sector, patients need to buy government-sponsored health insuranceor pay a fee to receive a referral to the ‘free’ Chest Clinic. Confusion over howthe referral system works is another important barrier.

There are unrecognised costs of seeking care, such as‘special food’ and lost income. In addition, patients travelling to seek carespend 16 percent of their monthly income on transport. Others simply cannot getcare if they are too ill to walk. Patients are often tempted to travel if they thinkthat a more distant facility provides a better service or a more reliable drugsupply.

These results have implications for the impact of reforms proposedfor TB programmes in sub-Saharan Africa, particularly decentralisation. Underdecentralisation, TB diagnosis occurs at neighbourhood clinics. This reducesthe number of health encounters and travel distances involved. It may also cutcongestion at larger hospitals with an opportunity to improve quality of carethere. However, the extra burden of TB care may overstretch under-fundedprimary health services.

No single ideal decentralised design for TB treatment exits– each country must consider its own resources in the decision-making process. Twocritical success factors are a minimum level of financial resources andinfrastructure and parallel reform throughout the entire public sector. For successfuldecentralisation, the researchers recommend:

• accessing extra donor and private funding
• cutting costs by downsizing specialist hospitalcare
• reassessing the system of health referral
• providing education and financial or otherincentives to all health care providers to refer patients to the TB programme
• redesigning TB clinic logistics to be more patient-friendly
• providing communicationskills training for TB clinic staff.

Another proposed reform is the integration of TB programmeswith other health services. TB programmes could offeraccess to free anti-TB drugs via private practitioners. They could also utilisethe convenient location and familiarity of traditional healers. This potentialreform will need ongoing education of private practitioners. Further integrationof TB and HIV programmes may also be critical to reducing patient barriers tocare-seeking. This could involve:

• community and volunteer involvement
• local income generation projects
• evaluation of cost savings from integration
• specific donor funding.

In much of sub-Saharan Africa, poorly resourced primaryhealth care services are already under severe pressure. Any reform of TBprogrammes must be based upon a strengthening of the infrastructure and fundingfor local health care services to ensure that policies, such asdecentralisation, do not harm care-seeking and the running of facilities.