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• W2891431475 abstract "Tuberculosis is fundamentally a disease of poverty; being poor increases the risk of falling sick with tuberculosis. Falling sick with tuberculosis also leads to impoverishment that can trigger a downward spiral of worsening health, ongoing tuberculosis transmission, crippling medical expenses, which further entrench poverty.1Lonnroth K Glaziou P Weil D Floyd K Uplekar M Raviglione M Beyond UHC: monitoring health and social protection coverage in the context of tuberculosis care and prevention.PLoS Med. 2014; 11: e1001693Crossref PubMed Scopus (96) Google Scholar Because of these realities, purely biomedical or public health solutions are not enough to end the tuberculosis epidemic; countries must implement social policy strategies that can protect tuberculosis sufferers from the financial shocks of this deadly disease. In September 2018, the UN will convene a High-Level Meeting (HLM) to ensure that Heads of States and Governments commit to ending this epidemic. This meeting provides a unique opportunity to underscore the importance of social protection interventions in ending tuberculosis. Here, we present compelling evidence for why such interventions represent a critical investment for high-burden countries and global partners. Substantial research demonstrates that tuberculosis perpetuates poverty, causes substantial losses in productivity for already poor individuals (3–4 months of work), families (30% of yearly household earnings), and countries (4–7% of GDP).2Laxminarayan R Klein E Dye C Floyd K Darley S Adeyi O Economic benefit of tuberculosis control (English). Policy Research working paper. World Bank, Washington, DC2007Google Scholar National surveys in seven countries3Wingfield T WHO Taskforce on Measurement of Catastrophic Cost of TuberculosisImplementation of the World Health Organization's Tool for Measuring TB Patient Costs: country level results, adaptations, and future directions.Int J Tuberc Lung Dis. 2017; 21 (abstr 33).: S26PubMed Google Scholar demonstrate that patients who develop tuberculosis often face catastrophic costs (>20% household income) just to obtain tuberculosis services driven by high direct and opportunity costs related to accessing tuberculosis diagnostic and treatment care. In high-burden countries that have conducted patient-costing surveys, up to 83% of tuberculosis-affected households were reported to experience catastrophic costs, and up to half to have taken out loans or sold assets (so-called dissavings).4WHOGlobal Tuberculosis Report 2017. World Health Organization, Geneva2017Google Scholar Significant social and economic burdens make patients with tuberculosis less likely to present for care, complete tuberculosis testing, and initiate treatment,5Hargreaves JR Boccia D Evans CA Adato M Petticrew M Porter JD The social determinants of tuberculosis: from evidence to action.Am J Public Health. 2011; 101: 654-662Crossref PubMed Scopus (270) Google Scholar leading to increased transmission, morbidity, and mortality.6Dye C Lonnroth K Jaramillo E Williams BG Raviglione M Trends in tuberculosis incidence and their determinants in 134 countries.Bull World Health Organ. 2009; 87: 683-691Crossref PubMed Scopus (256) Google Scholar With the WHO's End TB Strategy7Uplekar M Weil D Lonnroth K et al.WHO's new end TB strategy.Lancet. 2015; 385: 1799-1801Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar and the Sustainable Development Goals (SDG) Agenda,8Assembly UNG Transforming our world: the 2030 Agenda for Sustainable Development. United Nations, New York2015Google Scholar there is a renewed policy interest in integrating social, economic, and health goals, targets, and indicators. This interest includes setting targets such as 0% of tuberculosis-affected households incurring catastrophic costs,7Uplekar M Weil D Lonnroth K et al.WHO's new end TB strategy.Lancet. 2015; 385: 1799-1801Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar using tuberculosis as a “tracer” disease to measure achievement of the SDGs,8Assembly UNG Transforming our world: the 2030 Agenda for Sustainable Development. United Nations, New York2015Google Scholar linking socioeconomic indicators with tuberculosis indicators in standard public health platforms, and supporting universal health coverage (UHC) for all. While we acknowledge that progress towards UHC is essential to ending the epidemic, we argue that guaranteeing UHC in high-burden countries will be insufficient to address the tuberculosis epidemic. Social protection interventions that prevent or mitigate other financial risks associated with tuberculosis, such as income losses and non-medical expenditures, must also be considered.1Lonnroth K Glaziou P Weil D Floyd K Uplekar M Raviglione M Beyond UHC: monitoring health and social protection coverage in the context of tuberculosis care and prevention.PLoS Med. 2014; 11: e1001693Crossref PubMed Scopus (96) Google Scholar Examples of social protection include interventions from cash transfers and nutrition programmes offered by individual clinics to social welfare systems adopted as part of national policies. They can contribute to successful tuberculosis outcomes both through indirect means, addressing social, biological, and structural determinants, or through direct means that enable access to care.5Hargreaves JR Boccia D Evans CA Adato M Petticrew M Porter JD The social determinants of tuberculosis: from evidence to action.Am J Public Health. 2011; 101: 654-662Crossref PubMed Scopus (270) Google Scholar The table summarises country-based social protection interventions in various stages of implementation and evaluation. Ecological and modelling studies suggest that countries that increase spending on social protection programmes have an associated decrease in tuberculosis incidence and prevalence, and a reduction in mortality.9Siroka A Ponce NA Lonnroth K Association between spending on social protection and tuberculosis burden: a global analysis.Lancet Infect Dis. 2016; 16: 473-479Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 10Carter DJ Glaziou P Lonnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar Recent models leveraging data from 192 countries to link the SDG targets to tuberculosis outcomes, suggest that expanding social protection schemes to all eligible populations could decrease tuberculosis incidence by 76%,10Carter DJ Glaziou P Lonnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar underscoring its potential impact when used in tandem with proven biomedical interventions.TableExamples of social protection programmes and policies in high-tuberculosis-burden settings under studyInterventionImpactInvestigatorsTuberculosis-specific strategiesIndiaUnconditional cash transfer to support treatment adherence and offset costs of food and transportationPending evaluation*Pending evaluation refers to unknown status of evaluation studies for ongoing pilot interventions.NANigeriaUnconditional cash transfers for treatment adherenceImproved treatment success (~15%)Ukwaja, 2017BrazilFood baskets and nutrition supportStudy ongoing†Study ongoing acknowledges that evaluation studies of the pilot intervention are in process, with data collection, analysis, and or result dissemination underway.Maciel, 2018VietnamSocial health insurance plus unconditional cash transfersStudy ongoing†Study ongoing acknowledges that evaluation studies of the pilot intervention are in process, with data collection, analysis, and or result dissemination underway.NAMoldovaCash transfers or food vouchers or transportation vouchersImproved treatment outcome and reduced loss to follow-up and mortalityCiobanu, 2014PeruConditional cash transfers plus social supportImproved economic outcomesWingfield, 2017KenyaMedical insurance coverage, food support, and cash transfersPending evaluation*Pending evaluation refers to unknown status of evaluation studies for ongoing pilot interventions.NATuberculosis-sensitive strategiesBrazilConditional cash transfers based on incomeImproved tuberculosis cure rate (7–10%)Torrens, 2016; Nery, 2017; Maciel, 2018;IndonesiaUniversal health coverageNo difference in catastrophic costs burdenFuady 2018NA=not available.* Pending evaluation refers to unknown status of evaluation studies for ongoing pilot interventions.† Study ongoing acknowledges that evaluation studies of the pilot intervention are in process, with data collection, analysis, and or result dissemination underway. Open table in a new tab NA=not available. What can be done now to start implementing a social protection agenda? First, we should support additional research on social protection and tuberculosis. Data are needed to understand the burden of catastrophic costs and dissavings, and how these measures influence tuberculosis and socioeconomic outcomes. Second, we should advocate for context-specific, multi-sectoral social protection policies and programmes; poverty-alleviation is not outside of our purview but is central to our work. Additional research that incorporates implementation science, health economics, and social epidemiology is needed to identify and design feasible, scalable social protection interventions that are context-specific. Finally, policies need to be established to give national tuberculosis programmes (NTPs) the support and mandate necessary to address the socioeconomic consequences of illness for their patients. In summary, to capitalise on the political opportunity that the HLM presents, the tuberculosis community must emphasise to Heads of States and Governments how a successful response to the epidemic needs to extend beyond biomedical solutions, and address all patient barriers to tuberculosis prevention and care. Further, by integrating social protection with tuberculosis care, we can model multisectoral approaches in policy, programme, and research that can be used to achieve disease elimination and simultaneously improve economic and development outcomes for the world's most vulnerable populations. We declare no competing interests." @default.
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• W2891431475 title "Message to world leaders: we cannot end tuberculosis without addressing the social and economic burden of the disease" @default.
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