Social Protection to End TB - UCSF Global Health Sciences

Social Protection to End TB - UCSF Global Health Sciences

Overcoming socioeconomic barriers to TB care: the case for social protection Priya B. Shete, MD March 23, 2018 UCSF-UCB World TB Day Goals and Objectives Present Background/Rationale for why Social Determinants and Social Protections are critical in TB Prevention and Care Present a variety of examples by which research can impact policy making in this field.

TB is a Disease of Poverty TB is caused by poverty: Social and structural determinants: national health expenditures, human development index, household income, lack of sanitation, poor nutrition TB perpetuates poverty: 4-7% decrease in GDP 3-4 months loss of productivity/work 30% decrease in household income & catastrophic costs How are we addressing this? Dye, 2011; Lonnroth, 2011; Hargreaves 2015

Ending TB in the Era of the SDGs Uganda Significant Patient Attrition in the TB Cascade of Care Only 29% of patient suspected of having TB complete smear examination if referred ~75% of patients initiate treatment if smear positive 45% of Patients microbiologically diagnosed by GeneXpert do not initiate treatment Davis JL, AJCCRM 2011 Shete PB, IJTLD 2017

Farr, ERS 2017 Pathways to Care in Uganda Shete IJTLD 2015 Costs of Accessing TB Diagnostic Care in Uganda Patients Spent a Median of 28.8% of their MMHI on accessing TB Diagnostic Care This is CATASTROPHIC! Shete, IJTLD 2015

SES Consequences of TB related Symptoms Socioeconomic Indicator % Participants (n=465) Change in individual Income -40% Change in Household Median Monthly Income -44%

Cost of current visit alone (%HHMI) 17% Households who experienced Dissavings 36% Household who unenrolled a child from school

12% <2% of participants received any social protections including health insurance 64% of patients report significant SES impact 41% would not go for additional testing Shete, unpublished data What is Social Protection? Social Protections are interventions that address individuals social and economic risk: health insurance, disability benefits, food baskets, microfinance, cash transfers, social support groups.

Can social protections enable behavior change (nudge) and improve outcomes (health and poverty alleviation)? Social protection strategies Indirect effect Better education Better access to social/health services Better Food security / food consumption Crowding Housing quality Poor ventilation

Exposure risk Biological risk factors* Infection risk Direct effect Better access to TB care resulting from conditionalities specific for TB care

Higher household / individual socioeconomic position Individual / household food security/ food consumption patterns Disease Progression risk Time and quality of diagnosis Prevention

Health seeking behaviors Treatment outcome Treatment TB prevalence in the community TB associated costs

Support MDR-TB prevalence in the community Community economic growth Social cohesion Country security Policy Solutions - Universal Health Coverage or TB Specific Social Protections or Both? - Cash Transfers may improve economic outcomes protection (29% decrease in catastrophic costs).

- Modelling studies with data from 192 countries demonstrate improved TB indicators (70% decrease in incidence) with scale up of social protection (Carter, Boccia submitted) - Can this be implemented and how? Brazil Brazil and Bolsa Famlia Program(BFP) Conditional Cash Transfer Program for Impoverished Households linked to pro-health behaviors 40 million recipients Linked to significant health outcomes: U5MR, peri-natal mortality,

maternal mortality, nutrition Effect of Bolsa Famlia Program TB Treatment Outcome Prospective cohort study of 1,239 individuals on TB treatment in seven Brazilian capital cities Data obtained from March 2014 to April 2017 Logistic model with propensity score Cure Dropout Death Coef.

0076 -0070 -0002 95%CI 0037 0116 -0105 -0036 -0021 0017 p value <0001 <0001 0836

Almost 8% improvement in Cure rate, but major Likely underestimate because of those TB patients who were eligible but did not receive the benefit. Maciel & Shete, Submitted Next Steps Need for better linked social, economic, and health indicators. Need for formative research describing modifiable barriers and enablers for social protection interventions in multiple contexts. Need for context specific policy translation frameworks and research to support them (quasi-experimental designs, trials) Need to use our research and academic platforms to advocate for social

justice and equity. Acknowledgments Adithya Cattamanchi, Phil Hopewell, Delia Boccia, Tom Wingfield, Carlton Evans, Knut Lonnroth, Christian Lienhardt, David Dowdy, David Moore, Luke Davis, Diana Weil, Denise Arakaki- Sanchez, Ethel Maciel, Achilles Katamba, Talemwa Nalugwa, Sarah Nabwire, Katherine Farr, Justin White Thanks for support from : UCSF CFAR, Parker B. Francis Family Foundation, World Health Organization

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