1	Poverty & TB: Global Overview and Kenyan case study Christy Hanson, PhD, MPH PATH May 30, 2005 CCIH Annual Conference
2	Global TB Control: TB facts TB is infectious, curable disease 8.8 million new cases of TB in 2003 TB is the primary cause of death for PLWHA in Africa Highly cost-effective treatment strategy Only half of new cases were detected in 2003
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6	Africa: HIV driving the TB epidemic TB notification rates, 1980-2003
7	TB and HIV in Kenya
8	Global Targets for TB control 70% case detection 85% treatment success
9	TB can be cured: DOTS strategy Political commitment Standardized treatment regimen Available free of charge to patients in public sector Diagnosis by smear microscopy Directly-observed treatment (DOT) Standardized recording and reporting Quality control
10	DOTS Works China DOTS areas: 44% decrease in TB prevalence (1990-2000) Non-DOTS areas: 12% decrease in TB prevalence Global level DOTS areas: treatment success rates average 80% Non-DOTS areas: around 50%
11	Evolution of DOTS
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13	Challenges for the future of TB control Dual epidemic of TB/HIV Low case detection rates
14	Poverty: Inequity between countries
15	Distribution of Poverty
16	Causes of Poor-Rich Health Status Gap
17	Disproportionate disease burden among the poor*
18	22 Highest TB burden countries None are high-income countries 78% have GNP per capita of less than $760 (low income) Estimate: over 50% new TB patients without access to DOTS are living on less than $2 per day
19	Korea case study
20	Poverty: Inequity within countries
21	TB prevalence among poor and non-poor, Philippines
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23	TB in the homeless
24	Poverty: Individual level
25	TB Epidemiology
26	Income poverty and TB
27	Poverty links to TB exposure, infection and disease Overcrowding Malnutrition TB anemia, low retinol & zinc, wasting Vit D deficiency 10x risk of TB disease Gender differentials Higher prevalence among men Women:faster breakdown to TB disease (2x) Marginalized populations Ethnicity Prisoners
28	TB case rates by SES indicator: United States 1987-1993
29	Poverty & TB disease outcome Impoverishing effects of TB Economic: 20-30% of household wages Social: stigma Women fear social impoverishment, men fear economic Delayed treatment seeking Worse outcomes? Barriers to access Inhibited continuity In absence of treatment, 50% will die
30	Reasons for treatment delay: China
31	Global Response to Health Inequities Millennium Development Goals Halve the prevalence of TB disease and deaths between 1990 and 2015 Poverty-Reduction Strategy Papers Re-orienting development agenda toward pro-poor approaches Debt-relief, increased funds for social sectors Global Fund for AIDS, TB and malaria 4 rounds of applications funded over $8 billion approved $1 billion for TB (13%)
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33	Financing public health: caring for the poor?
34	Financial subsidy from Government health services to poorest & richest 20%
35	Expenditures on TB care by level of wealth
36	Mounting a response
37	TB community response to TB and poverty DOTS expansion and adaptation Global TB Drug Facility Stop TB Partnership Collaboration with NGOs, partners Social and resource mobilization 2002 Theme: TB and poverty Research Benefit - incidence Evaluating what works Understanding what matters to the poor (demand)
38	Addressing barriers to care: Examples Cambodia: food incentives for all TB patients Uganda: community-based care China: increased financing for TB control in poorest areas Kenya: mobile treatment facilities for migrant populations Mauritania: salary supplements for health workers in poor, rural areas
39	Kenyan Case Study Is the health system responding to poverty dimension of TB?
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41	Evidence of link: TB incidence and poverty
42	Evidence of link: TB incidence and poverty
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45	Wealth of TB patients & poverty in their provinces
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50	Conclusions & Next steps TB patients actively seeking care Poor disproportionately represented at all stages Research: prevalence distribution by wealth Social science research: why? Private sector: competitive, well used Cost & geographic access similar District variance: lessons to be learned from successful districts Modeling of system and district-level determinants impacting case detection New initiatives: test strategies to reach the poor
51	Conclusions TB disproportionately affects the poorest countries & poorest populations TB has impoverishing effects on individuals and households TB can be cured DOTS is cost-effective and adaptable to become pro-poor Equity approach to the expansion of DOTS needed Attain global targets Serve local populations
52	Voices of the poor: Can anyone hear us? “The authorities don’t seem to see poor people. Everything about the poor is despised, and above all, poverty is despised.” - Brazil, 1995