Dissaving In the Era of “Free” Care for Tuberculosis (TB): A Qualitative Exploration of Financial Coping and Enablers Among Patients with Co-Prevalent TB-HIV/ TB-Diabetes in Bhavnagar Region, Western India

Mihir Rupani; Sheetal Vyas

doi:10.55489/njcm.130920222242

Authors

Mihir Rupani Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Bhavnagar, Gujarat, India; Clinical Epidemiology (Division of Health Sciences), ICMR - National Institute of Occupational Health (NIOH), Ah-medabad, India; Ph.D. scholar affiliated to Gujarat University, Ahmedabad, India https://orcid.org/0000-0003-2174-1345
Sheetal Vyas AMC-MET Medical College, Ahmedabad, India; Ph.D. guide affiliated to Gujarat University, Ahmedabad, India

DOI:

https://doi.org/10.55489/njcm.130920222242

Keywords:

tuberculosis-diabetes, negative financial coping, collaborative framework, financial protection, TB-HIV

Abstract

Background: India reports the highest number of cases of tuberculosis (TB) in India. Patients with TB employ negative financial coping mechanisms (dissaving) to make up for the costs of care. Our objectives were to explore the dissaving employed and enablers perceived by patients with TB-HIV, patients with TB-diabetes, and program managers of TB.

Methods: We conducted qualitative in-depth interviews among eight TB-HIV patients, eight TB-diabetes patients, and seventeen program managers of TB in the Bhavnagar region (western part of India). An interview guide focusing on the coping strategies and enablers was used. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis (codes and categories).

Results: Borrowing money, taking a loan on interest, selling jewellery, taking up employment by the spouse, and mortgaging assets were the negative financial coping strategies employed by patients with TB-HIV co-infection/ TB-diabetes comorbidity. Free diagnosis, free treatment, accessible health facilities, support from health workers, bi-directional screening, and collaborative integration were some of the enablers perceived by patients and program managers.

Conclusions: Even in settings with a decentralized “free” model of TB care, patients with co-prevalent TB-HIV/ TB-diabetes employ dissaving to offset the costs of care. The cash transfer scheme for patients with TB should be realigned to meet the financial protection targets of zero catastrophic costs by the year 2030.

References

World Health Organization. Global Tuberculosis Report 2021 [Internet]. Geneva: World Health Organization; 2021. Available from: https://apps.who.int/iris/rest/bitstreams/1379788/retrieve

World Bank Group. Poverty & Equity Brief: South Asia - India [Internet]. 2020 [cited 2022 Jul 2]. Available from: https://databank.worldbank.org/data/download/poverty/33EF03BB-9722-4AE2-ABC7-AA2972D68AFE/Global_POVEQ_IND.pdf

Wingfield T, Boccia D, Tovar M, Gavino A, Zevallos K, Montoya R, et al. Defining Catastrophic Costs and Comparing Their Importance for Adverse Tuberculosis Outcome with Multi-Drug Resistance: A Prospective Cohort Study, Peru. Ruger JP, editor. PLoS Med [Internet]. 2014 Jul 15;11(7):e1001675. Doi: https://doi.org/10.1371/journal.pmed.1001675 PMid:25025331 PMCid:PMC4098993

Ghazy RM, El Saeh HM, Abdulaziz S, Hammouda EA, Elzorkany AM, Khidr H, et al. A systematic review and meta-analysis of the catastrophic costs incurred by tuberculosis patients. Sci Rep [Internet]. 2022;12(1):1-16. Doi: https://doi.org/10.1038/s41598-021-04345-x PMid:35017604 PMCid:PMC8752613

Rupani MP, Cattamanchi A, Shete PB, Vollmer WM, Basu S, Dave JD. Costs incurred by patients with drug-susceptible pulmonary tuberculosis in semi-urban and rural settings of Western India. Infect Dis Poverty [Internet]. 2020 Dec 19;9(1):144. Available from: https://idpjournal.biomedcentral.com/articles/10.1186/s40249-020-00760-w Doi: https://doi.org/10.1186/s40249-020-00760-w PMid:33076969 PMCid:PMC7574230

Mullerpattan JB, Udwadia ZZ, Banka RA, Ganatra SR, Udwadia ZF. Catastrophic costs of treating drug resistant TB patients in a tertiary care hospital in India. Indian J Tuberc [Internet]. 2019 Jan;66(1):87-91. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0019570717301993 Doi: https://doi.org/10.1016/j.ijtb.2018.04.011 PMid:30797290

Aung ST, Thu A, Lin Aung H, Thu M. Measuring Catastrophic Costs Due to Tuberculosis in Myanmar. 2021 [cited 2022 Jul 3]; Doi: https://doi.org/10.3390/tropicalmed6030130 PMid:34287379 PMCid:PMC8293353

Viney K, Itogo N, Yamanaka T, Jebeniani R, Hazarika A, Morishita F, et al. Economic evaluation of patient costs associated with tuberculosis diagnosis and care in Solomon Islands. BMC Public Health [Internet]. 2021 Dec 1 [cited 2022 Jul 3];21(1):1-14. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11938-8 Doi: https://doi.org/10.1186/s12889-021-11938-8 PMid:34688266 PMCid:PMC8542301

Gurung SC, Rai B, Dixit K, Worrall E, Paudel PR, Dhital R, et al. How to reduce household costs for people with tuberculosis: a longitudinal costing survey in Nepal. Health Policy Plan [Internet]. 2021 Jun 3 [cited 2022 Jul 3];36(5):594-605. Available from: https://academic.oup.com/heapol/article/36/5/594/6042349

Prasanna T, Jeyashree K, Chinnakali P, Bahurupi Y, Vasudevan K, Das M. Catastrophic costs of tuberculosis care: a mixed methods study from Puducherry, India. Glob Health Action [Internet]. 2018 Jan 14;11(1):1477493. Available from: https://www.tandfonline.com/doi/full/10.1080/16549716.2018.1477493 Doi: https://doi.org/10.1080/16549716.2018.1477493 PMid:29902134 PMCid:PMC6008578

Meghji J, Gregorius S, Madan J, Chitimbe F, Thomson R, Rylance J, et al. The long term effect of pulmonary tuberculosis on income and employment in a low income, urban setting. Thorax [Internet]. 2021 Apr 1 [cited 2022 Jul 2];76(4):387-95. Available from: https://thorax.bmj.com/lookup/doi/10.1136/thoraxjnl-2020-215338 Doi: https://doi.org/10.1136/thoraxjnl-2020-215338 PMid:33443228 PMCid:PMC7982936

Ayé R, Wyss K, Abdualimova H, Saidaliev S. Factors determining household expenditure for tuberculosis and coping strategies in Tajikistan. Trop Med Int Heal [Internet]. 2011 Mar [cited 2022 Jul 3];16(3):307-13. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1365-3156.2010.02710.x Doi: https://doi.org/10.1111/j.1365-3156.2010.02710.x PMid:21214691

Laokri S, Dramaix-Wilmet M, Kassa F, Anagonou S, Dujardin B. Assessing the economic burden of illness for tuberculosis patients in Benin: determinants and consequences of catastrophic health expenditures and inequities. Trop Med Int Heal [Internet]. 2014 Oct 1 [cited 2022 Jul 3];19(10):1249-58. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.12365 Doi: https://doi.org/10.1111/tmi.12365 PMid:25040399

Pedrazzoli D, Siroka A, Boccia D, Bonsu F, Nartey K, Houben R, et al. How affordable is TB care? Findings from a nationwide TB patient cost survey in Ghana. Trop Med Int Heal [Internet]. 2018 Aug 25 [cited 2022 Jul 3];23(8):870-8. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.13085 Doi: https://doi.org/10.1111/tmi.13085 PMid:29851223

Jackson S, Sleigh AC, Wang GJ, Liu XL. Poverty and the economic effects of TB in rural China. Int J Tuberc Lung Dis [Internet]. 2006 Oct;10(10):1104-10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17044202

Foster N, Vassall A, Cleary S, Cunnama L, Churchyard G, Sinanovic E. The economic burden of TB diagnosis and treatment in South Africa. Soc Sci Med [Internet]. 2015 Apr 1 [cited 2022 Jul 3];130:42-50. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0277953615000726 Doi: https://doi.org/10.1016/j.socscimed.2015.01.046 PMid:25681713

Madan J, Lönnroth K, Laokri S, Squire SB. What can dissaving tell us about catastrophic costs? Linear and logistic regression analysis of the relationship between patient costs and financial coping strategies adopted by tuberculosis patients in Bangladesh, Tanzania and Bangalore, India. BMC Health Serv Res [Internet]. 2015 Oct 22 [cited 2022 Jul 3];15(1):1-8. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-1138-z Doi: https://doi.org/10.1186/s12913-015-1138-z PMid:26493155 PMCid:PMC4618866

Hutchison C, Khan MS, Yoong J, Lin X, Coker RJ. Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China. BMC Public Health [Internet]. 2017 Feb 22 [cited 2022 Jul 3];17(1):1-11. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4089-y DOi: https://doi.org/10.1186/s12889-017-4089-y PMid:28222724 PMCid:PMC5320743

Arnold M, Beran D, Haghparast-Bidgoli H, Batura N, Akkazieva B, Abdraimova A, et al. Coping with the economic burden of Diabetes, TB and co-prevalence: Evidence from Bishkek, Kyrgyzstan. BMC Health Serv Res [Internet]. 2016;16(1):1-13. Doi: https://doi.org/10.1186/s12913-016-1369-7 PMid:27048370 PMCid:PMC4822315

Mudzengi D, Sweeney S, Hippner P, Kufa T, Fielding K, Grant AD, et al. The patient costs of care for those with TB and HIV: a cross-sectional study from South Africa. Health Policy Plan [Internet]. 2017 Nov 1;32(suppl_4):iv48-56. Available from: https://academic.oup.com/heapol/article/2999103/The Doi: https://doi.org/10.1093/heapol/czw183 PMid:28204500 PMCid:PMC5886108

Navya N, Jeyashree K, Madhukeshwar AK, Anand T, Nirgude AS, Nayarmoole BM, et al. Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India. BMC Health Serv Res [Internet]. 2019 Dec 1;19(1):90. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-3913-8 Doi: https://doi.org/10.1186/s12913-019-3913-8 PMid:30709351 PMCid:PMC6359801

Amo-Adjei J, Awusabo-Asare K. Reflections on tuberculosis diagnosis and treatment outcomes in Ghana. Arch Public Heal [Internet]. 2013 Dec 23 [cited 2022 Jul 5];71(1):22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765431/ Doi: https://doi.org/10.1186/2049-3258-71-22 PMid:23971675 PMCid:PMC3765431

Haldane V, Zhang Z, Ma Q, Yin T, Zhang B, Li Y, et al. A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China. Infect Dis Poverty [Internet]. 2021 Dec 20 [cited 2022 Jul 5];10(1):120. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451167/ Doi: https://doi.org/10.1186/s40249-021-00906-4 PMid:34544492 PMCid:PMC8451167

Adam C, Potvin L. Understanding exclusionary mechanisms at the individual level: a theoretical proposal. Health Promot Int [Internet]. 2016 Apr 20 [cited 2022 Jul 6];32(5):daw005. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914318/ Doi: https://doi.org/10.1093/heapro/daw005 PMid:27099238 PMCid:PMC5914318

Dave JD, Rupani MP. Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? - A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India. Int J Heal Policy Manag [Internet]. 2022 Jan 30; Available from: https://dx.doi.org/10.34172/ijhpm.2022.5784 Doi: https://doi.org/10.34172/ijhpm.2022.5784 PMid:35174676

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Heal Care [Internet]. 2007 Sep 16;19(6):349-57. Available from: https://academic.oup.com/intqhc/article-lookup/doi/10.1093/intqhc/mzm042 Doi: https://doi.org/10.1093/intqhc/mzm042 PMid:17872937