A wide-ranging, six year, multi-layered and multi-location project involving Duke University/Duke Kunshan University, the China Centers for Disease Control and Prevention (China CDC), The Gates Foundation, four Chinese universities and local health care providers examined TB care and medication use in China from 2009-2015, as well as financing of health care related to TB. Ten papers presenting a broad set of findings and recommendations for affordable and efficient TB care were published in the latest special issue of Infectious Diseases of Poverty in January. Some of the researchers’ recommendations are already being implemented at the project sites.
In 2013, the World Health Organization (WHO) estimated that China had the second highest burden of both tuberculosis (TB) and multi-drug resistant tuberculosis (MDR-TB) in the world. Although the 2010 Epidemiology Survey revealed an impressive 65 % decline in smear-positive pulmonary TB between 1990 and 2010, the high prevalence of TB is still a serious concern in many parts of China.
Lead author Shenglan Tang, professor of the Duke Global Health Institute and the Global Health Research Center at Duke Kunshan University, pointed out, ‘while basic TB care in China is free of charge, the more complex MDR-TB adds a significant layer of expenses. And there are additional charges related to medication, patient transportation and hospital stays that add an extra financial burden to patients, especially the poor.’
Final evaluation meeting in Yichang, Hubei
This project, entitled ‘China’the Gates Foundation Collaboration on TB Control in China’, mainly focused on TB/MDR-TB care, financing and related policies, and aims to provide more affordable and efficient care for TB patients. In its first phase, researchers investigated the diagnosis, treatment and financing of care related to MDR-TB. During this period, an important change in TB care and control system took place in China, which was that tasks of TB diagnosis and treatment were shifted from CDC to the hospital system. An increasing number of county general hospitals were appointed as TB designated hospitals. In addition, health insurance schemes superseded the special fund from the Ministry of Finance, and became the main provider of funding for TB services.
In order to implement the changes and scale up, the research moved the project into its second phase in 2012. Researchers then started an in-depth examination of TB/MDR-TB care and financing, and found both an over-provision and under-provision of TB care in Chinese hospitals due to a combination of inappropriate economic incentives, lack of knowledge about infectious disease control and misguided health insurance policies. Besides, the major health insurers in China failed to provide adequate financial protection for TB patients, and catastrophic health expenditure in TB care seeking was not uncommon. Treatment of TB was unbalanced on the whole: researchers found that more than half of inpatients with TB might be treated incorrectly and the overuse of second-line TB drugs was a serious problem, resulting in poor treatment outcomes and a lack of economic efficiency.
Researchers extracting data from hospital health information system (HIS) in Wufeng, Yichang, Hubei
Therefore, researchers and collaborators developed and implemented new financing models for TB and MDR-TB care and control in three cities across China: Zhenjiang City, Jiangsu Province in the eastern region; Yichang City, Hubei Provence in the central region; and Hanzhong City, Shaanxi Province in the western region. With the strong support from the Gates Foundation and international experts, representatives from health insurance management agencies, government agencies responsible for poverty reduction, and municipal governments developed two major reforms for the financing of TB care which were put in place at the three research program sites in 2014 – First, all of the health insurance schemes agreed to increase the rate at which they reimburse hospitals for TB care; second, a new reimbursement mechanism was implemented at the TB-designated hospitals in order to incentivize them to provide the recommended treatment and contain costs.
Prof. Tang Shenglan said this research project revealed the full range of issues surrounding TB care and financing in China. ‘Without research and the findings we published today, we wouldn’t have a true sense of the scope of the challenges,’ he said. ‘This project has given the partners a roadmap for how to move forward to change policies and practices that will result in better, and more affordable care for TB patients. With support from the Gates Foundation, appropriate policy interventions on healthcare financing have been underway in the three project provinces over the past two years. In addition, promising results related to improved access to and financing of TB care and control are emerging.’
The ‘China’the Gates Foundation Collaboration on TB Control in China’ research project was jointly funded by the Chinese National Health and Family Planning Commission, the China CDC and the Bill and Melinda Gates Foundation.
