Summary of findings
Overall, low income patients, defined at household or district level, pay large amounts of money for medical treatment of TB, ranging from US$ 149 to 724 (RMB 1241 to 5228); as a percentage of annual household income, estimates range from 42% to 119%. One national survey showed 73% of TB patients at survey had interrupted or suspended treatment, and estimates from 9 smaller more recent studies of showed that the proportion of patients at the time of the survey who had run out of drugs or were not taking them ranged from 3 to 25%. Synthesis of surveys and qualitative research indicate that cost is the most cited reason for default.
In a primary health care system where fee for service is normal, the Chinese government commendably made TB drugs free. However, charges remain universal. It appears free drugs are overlaid on an existing health system based on fee for service, which proves problematic given the existing organisational norms and culture. The charges arise from additional and often unnecessary drugs and tests beyond those supplied through the national programme .Thus the revenue-driven practices in the general health system are influencing TB control, including overprovision, poor referral (to keep patients), and high hospitalisation costs [1, 9].
We did identify policies to try and mitigate treatment cost but data were limited. A number of pilot schemes are underway, including decentralisation of TB diagnosis and case management services to the township level ; travel subsidies to get to clinic; payment to doctors for directly observing treatment ; free treatment for migrant patients ; and schemes linked to the New Cooperative Medical Scheme (NCMS), including case based payment.
The NCMS in China since 2003 has reached over 90% of the rural population, and has improved the use of healthcare by insured rural residents [28, 29]. However, reimbursement is low, and ambulatory patients with chronic diseases have limited financial protection, and still have to pay considerable amounts out of pocket [30–32].
It seems inevitable that this will impact on completion rates. Using surveys, there is a large variation in estimates of TB completion. The national TB survey in 2000 reported a low adherence rate, particularly low in the general health system. In recent studies reported here, the results are the proportion of patients not taking drugs at the time of the survey: the cumulative failure to complete is likely to be higher. Hence, the adherence on average was not so optimistic. What these data do is generate a degree of uncertainty around true completion rates.
TB treatment completion rate from the independent studies reported in this review contrast with published health service statistics which show very good performance . The Ministry of Health in China and others have very clear targets for detection and treatment, set by government and endorsed by World Health Organization. It may be that the actual health information systems do not operate as well as expected, and where there are gaps in the data, health workers worldwide tend to take the most optimistic standpoint in their estimates. Thus the imputed completion rates may be overly optimistic. This we have found in a study in Chongqing , although there has been very little systematic assessment of the extent of this problem.
Given the number of patients in China, poor or irregular adherence could have massive public health implications, potentially increasing the risk of multi-drug resistant TB and extremely drug-resistant TB developing. This will cause a worsening of the TB epidemic in areas of China, and will increase the risk of morbidity and mortality among the poor as well as the costs associated with illness.