Disease Prevention and Control / Communicable Diseases / Tuberculosis

Addressing Poverty in TB Control: Options for National TB Control Programmes

Addressing Poverty in TB Control Programmes

Full Text (84 pp, PDF via WHO site)
Preface   |   Acknowledgements
Summary  | Introduction
Chapter 1: Rationale for integrating pro-poor and equity-enhancing measures in TB control
Chapter 2: Barriers to accessing TB services by poor and vulnerable groups
Chapter 3: Potential actions for overcoming barriers in accessing TB services
Chapter 4: Situations and population groups requiring special consideration
Chapter 5: Harnessing resources to deliver pro-poor TB services
Chapter 6: Assessing the pro-poor performance of TB services and impact of pro-poor measures
Annex: Practical steps to address poverty in TB control
- Useful addresses

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- Other WHO TB Publications
- WHO TB Page
- PAHO TB Page

(World Health Organization, 2005)

WHO's commitment to the promotion of equity and pro-poor policies in its disease prevention and control activities is based on the recognition of poverty as a major barrier to health and health care. In the case of TB, the links between poverty and disease burden have been documented for many years. This document addresses the integration of pro-poor measures in TB control programmes and offers guidance for national TB control programmes on the practical issues involved and options for action. The following six principal steps are recommended:

Step 1: Identify the poor and vulnerable groups in the country/ region served by the national TB control programme

  • Assess the poor and vulnerable groups who face barriers to accessing TB services, which may include:
    • those in absolute economic poverty;
    • those disadvantaged by gender-related factors;
    • marginalized ethnic groups;
    • people living in remote locations;
    • the urban poor;
    • other special situations and groups.
  • Establish a profile of poor and vulnerable groups and their locations in the country/region using:
    • government or other data on prevalence and distribution of poverty and vulnerable populations;
    • any government documents on poverty reduction plans or strategies;
    • information on which types of health-care providers are used by the poor;
    • data from any local studies on socioeconomic status of TB patients and poverty-related disparities.

Step 2: Determine which barriers prevent access of the vulnerable groups to services that provide TB diagnosis and treatment

  • Identify the types of barriers that may exist in the country/region, including economic barriers, geographical barriers, social and cultural barriers, health system barriers.
  • Determine, for each group, the main barriers involved in the country/region, such as:
    • economic barriers (complexity of the pathway to care, costs to patients);
    • geographical barriers (distance from and difficulty of journey to TB services);
    • social and cultural barriers (stigma, gender-related factors, fear of losing work, lack of knowledge of TB and the available services); and
    • health-system barriers (lack of responsiveness to the needs of the poor, effects of decentralization on peripheral services).

Step 3: Assess potential actions to overcome the barriers to access
Identify and prioritize actions to address the following:

  • Economic barriers
    • integration of TB services in primary health care;
    • encouragement of pro-poor, public-private mix for DOTS initiatives;
    • provision of TB diagnosis and treatment in the workplace;
    • extension of microscopy services;
    • avoidance of user fees;
    • provision of diagnosis and treatment free of charge;
    • discouragement of unofficial charges to patients.
  • Geographical barriers
    • extension of diagnostic and treatment services to remote, poor regions;
    • bringing patients from remote areas to TB services; development of a community-based TB care model.
  • Social and cultural barriers
    • promotion of community mobilization;
    • ensuring that staff attitudes do not reinforce stigma;
    • advocacy for worker protection to avoid loss of work as a result of TB;
    • ensuring that the TB health promotion plan takes account of poor and vulnerable groups;
    • ensuring that gender-related needs are addressed in TB control activities;
    • exploring possibilities for referral mechanisms from traditional health-care providers.
  • Health-system barriers
    • modification of schedules for TB diagnostic and treatment services to meet local needs;
    • developing the communication skills of staff; discouraging staff from discriminating against poor patients;
    • using total quality management to ensure that services remain responsive to the needs of the poor;
    • engaging in health service decentralization to promote capacity strengthening at the periphery and inclusion of TB control as a district-level priority.

Step 4: Review the situations and population groups requiring special consideration

  • Identify the groups needing special consideration and their locations in the country/region, including:
    • migrant populations (refugees, asylum-seekers, economic migrants, displaced populations, cross-border populations);
    • pockets of deprivation in wealthier countries (isolated ethnic minorities, homeless people and others); injecting drug users; prison populations.
  • Decide upon actions to address the special needs of these groups:
    • identify the specific needs of each of the groups;
    • establish priorities for action based on needs, feasibility, available resources, effectiveness of the measures;
    • examine current services available to the priority groups identified;
    • define strategies to ensure the diagnosis, treatment and follow-up of TB cases for each targeted group;
    • plan phased implementation of the pro-poor interventions selected.

Step 5: Explore possibilities for harnessing additional resources

  • Assess: Available strategies to engage in broad initiatives to improve access to
    • health services;
    • sources of funding for improvement of health outcomes;
    • institutions offering additional financial and other resources for pro-poor measures in TB control programmes;
    • human resources to expand the public and private sector involvement in TB services; and
    • technologies to enhance efficiency and effectiveness of TB services.
  • Facilitate access to additional resources by:
    • engaging in broader poverty reduction or health-sector plans;
    • identifying potential new partnerships in the country;
    • prioritizing mechanisms offering greatest added value for increasing access to DOTS services;
    • planning the preparation of proposals; involving other stakeholders in the planning process.

Step 6: Evaluate the impact of pro-poor measures

  • Establish the basis for impact evaluation by setting specific targets for TB control in poor and vulnerable populations, assessing the distribution of TB in the population and poverty-related disparities among DOTS beneficiaries.
  • Facilitate the monitoring of poverty-related inequalities and the impact of pro-poor interventions by:
    • identifying partners to carry out equity-monitoring;
    • including socioeconomic variables in routine data collection and analysis;
    • including socioeconomic questions in TB prevalence surveys;
    • conducting periodic studies of care-seeking and use of DOTS in health facilities; and
    • assessing who in the community benefits from DOTS services and who does not.

Note: The steps, factors to be considered, and potential actions are tabulated in the Annex, page 74.