National tuberculosis patients cost survey: research findings lead to change in policy and practice, Viet Nam

Abstract

In 2016, the Viet Nam National Tuberculosis Programme (NTP) conducted the first national TB patients cost survey to identify the main cost drivers to help guide cost mitigation policies and reduce financial barriers to the treatment of TB patients. The survey findings were widely disseminated and the NTP defined a roadmap. The major components of the roadmap included 1) advocating for patients to be covered by social health insurance; 2) creating a charity fund for TB patients; 3) strengthening the collaboration between the Ministry of Health and Ministry of Labour and Social Affairs; and 4) advocating for donor support. The first national TB patients cost survey has shown that a high proportion of TB patients incurred costs that were classed as ‘catastrophic’. The survey findings led to policy changes and new practices in Viet Nam.

Viet Nam is a lower middle-income country and ranks 16th among the 30 countries with the highest incidence of tuberculosis (TB).¹ One of the three targets of the 2015–2030 Global End TB Strategy is that no TB patient or their household should face catastrophic costs due to TB, and this is to be achieved by all countries by 2020.² Achieving this in Viet Nam will require appropriate health and social policies that minimise financial and economic costs incurred by TB patients for diagnosis, medicines and adherence to treatment. Until 2016, information on the magnitude of these financial and economic barriers and costs incurred by TB patients and their families was limited.

ASPECT OF INTEREST

From July to October 2016, the Viet Nam National Tuberculosis Programme (NTP), in collaboration with the WHO, conducted the first national survey of costs incurred by TB patients and their households in Viet Nam. The objectives of this study were to identify the main cost drivers to help guide cost mitigation policies and reduce financial barriers in accessing care and ensuring treatment adherence, and to establish a baseline for the WHO End TB indicator of zero TB-affected households with catastrophic costs in Viet Nam.³

The aim of the present paper is to describe how the findings of the first national TB patients cost survey have led to changes in policy and practices in Viet Nam.

The results of the first national TB patients cost survey in Viet Nam have been published elsewhere,³ and were widely disseminated (Table). An estimated 63% of TB patient households and 98% of the multi-drug-resistant TB (MDR-TB) patient households experienced total costs that were ‘catastrophic’ (defined as per the standard WHO definition, as the total costs due to TB in excess of 20% of the annual household income)., The cost incurred per household on average was US$1068 for an episode of drug-susceptible TB and US$4289 per episode of MDR-TB; the proportion of households below the international poverty line increased from 3.7% (before) to 21.4% (after) TB.³ The study concluded that a high proportion of TB patients incurred catastrophic costs, leading to calls for national policies to reduce both the direct and indirect costs incurred by patients.³ Due to the substantial post-disease costs associated with nutritional supplements, additional food, travel and accommodation, the removal of such barriers seems pertinent in lowering the financial burden imposed on patients.⁴

TABLE.

Dissemination of patient cost survey findings

The Viet Nam NTP have been sharing survey results at many international conferences and forums, including 1) the 47th and 48th Union World Conference on Lung Health 2016 and 2017;* 2) the first Health and Social Protection Action Research & Knowledge Sharing Network Consultation, Karolinska Institutet, Stockholm, Sweden (2016);† 3) the 11th National TB Programme Managers Meeting in the Western Pacific Region (2017);‡ and 4) the WHO Global Task Force on TB Impact Measurement 2018.

The Viet Nam NTP also collaborated with the WHO in organising a workshop in Hanoi, Viet Nam, in March 2017, to share the results of the national TB patient cost survey, discuss and identify key areas for policy actions, develop a framework for monitoring and evaluation, and undertake operational research on new policies, interventions and approaches.4

The main finding of this study has also been highlighted in the Global TB Report, as an example of national surveys of costs faced by TB patients and their households,5 and in Tuberculosis patient cost surveys: a handbook.5

^*47^th Union World Conference on Lung Health, 26–29 October 2016, Liverpool, UK; 48^th Union World Conference on Lung Health, 11–14 October 2017, Guadalajara, Mexico.

^†1^st SPARKS (Health and Social Protection Action Research & Knowledge Sharing) Consultation, 15–16 December, 2016, Karolinska Institutet, Stockholm, Sweden.

^‡11^th National TB Programme Managers Meeting in the Western Pacific Region, 19–21 March 2017, Tokyo, Japan,

In addition to disseminating the findings of the survey widely, the NTP developed a roadmap (2017–2020) involving non-health actors, which outlined the policies and interventions needed to reduce the costs faced by TB patients and their households. The roadmap was designed in collaboration with the Ministry of Labour-Invalids and Social Affairs (MOLISA) and other partners.⁵ The major components of the roadmap included 1) the development and costing of a package of ambulatory TB services to advocate for patients to be covered by social health insurance; 2) the launch of a charity fund for TB patients; 3) strengthening the collaboration between the Ministry of Health (MoH) and Ministry of Labour and Social Affairs; and 4) advocating for donor support.

The roadmap allowed the NTP and partners to identify key areas of policy action based on survey results, and also to develop a framework for monitoring, evaluation and operational research on new policies, interventions and approaches. The implementation of the framework in 2017–2018 involved 1) the establishment of a charity fund for TB patients called Patients Support to Fight TB (PASTB) by the Viet Nam NTP which has donated more than half a million US$ to TB patients; 2) collaboration between the NTP/MoH and MOLISA in implementing TB activities, including the work of scaling up and adapting supports to TB patients, e.g., purchasing health insurance cards for the poor and making existing general social protection schemes TB-sensitive; 3) assessment by NTP/MoH and MOLISA for additional financial and human resource needs, and training health service staff in social protection and social service staff on the relevant aspects of TB, as well as conducting joint MOLISA/MoH monitoring and evaluation; 4) assessment of current regulations for workers' protection by the NTP/MoH and MOLISA with a view to strengthening and making legal frameworks operational; 5) the development and costing by the NTP/MoH of a comprehensive package of ambulatory TB services to advocate for patients for social health insurance (SHI) coverage; 6) the inclusion of TB-specific social protection elements in the Global Fund Funding Request by the NTP for the period 2018–2020; 7) the creation of a national policy guide by NTP/MoH and MOLISA on interventions to reduce/compensate for patient costs; 8) evaluate the intervention (active case finding and comprehensive patient support) using IMPACT-TB study data to improve patient support and reduce patient costs; and 9) the creation of a global network involving the NTP, the WHO, the Health and Social Protection Action Research Knowledge Sharing (SPARKS) partners to facilitate action-oriented research on public health impact of social protection, with a focus on low- and middle-income countries and to adapt the SPARKS monitoring and evaluation framework for the assessment of new initiatives under the aegis of the Viet Nam Integrated Centre for TB and Respirology Research (VICTORY; Hanoi, Viet Nam).

DISCUSSION

The importance of operational research in changing policy

Pillar 3 of the three pillars defined in the WHO End TB Strategy comprises ‘intensified research and innovation’, which is essential in reaching the ambitious target of ending TB by 2035.² In Viet Nam, TB-related research is key to providing strategic information in ending TB. The section on operational research in the 2016–2020 Viet Nam National Strategic Plan includes an assessment of the TB burden in Viet Nam (prevalence and economic burden), as well as the current TB social protection programme in the country.

Policy and strategy changes

Evidence from the first national survey of costs borne by TB-affected households in Viet Nam (2016) established the basis for policy and strategy changes. A multi-stakeholder consultation in March led to the identification of actions needed to achieve Viet Nam NTP and the WHO End TB Strategy objectives.⁵ A joint action plan with the MOLISA was established in 2017. From March to September 2018, the Viet Nam NTP established a charity fund for TB patients, the PASTB; to date, more than half a million US$ has been donated by the charity to TB patients.

The first national TB patients cost survey in Viet Nam is also an example of good implementation of research uptake strategies that include stakeholder engagement, capacity building, communication and monitoring and evaluation.⁶ First, to ensure stakeholder engagement, the Viet Nam MoH/NTP has established VICTORY to take the lead in implementing and coordinating research in TB and lung disease, and develop a research network.⁷

Second, in terms of capacity building, the Viet Nam NTP has reinforced internal and external collaboration on research, and organised training courses and research workshops. However, in future the NTP will need to focus more on improving capacity to assess the impact of research.

Third, with regard to communication, the Viet Nam NTP established a communication plan targeting national and international workshops and conferences to disseminate survey findings to relevant audiences following the completion of the first national TB patients cost study.

Finally, with regard to monitoring and evaluation, following the establishment and implementation of the Viet Nam NTP and partners' roadmap and action plan, the NTP will be monitoring the outputs, outcomes and impact of the activities in the road-map and the action plan on social protection to improve patient support and reduce patient costs. In addition to monitoring progress towards End TB targets, the Viet Nam NTP also plans to conduct a second national TB patients costing study in 2020 to measure the impact of policy change with the help of the multisectoral roadmap.

CONCLUSION

The first national TB patients costing study has shown that a high proportion of TB patients incurred catastrophic costs, resulting in the call for national policies to reduce both the direct and indirect costs incurred by patients. Based on these survey findings, the NTP developed a roadmap outlining policies and interventions to reduce TB-related costs and compensate patients and their households. The survey findings have led to changes in policy and practices in Viet Nam, which will be monitored by the NTP and its partners through its operational research programme. A repeat NTP costing study is needed in 2020 to monitor progress in reducing the economic burden on TB-affected households and assessing the impact of these changes in policy and practice.