THE DYNAMICS OF TUBERCULOSIS AND POVERTY TRAPS IN INDIA

Friday, January 8, 2016
Foyer, G/F (Jockey Club School of Public Health and Primary Care Building at Prince of Wales Hospital)

Lea Prince, MA, PhD, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, CA, Kimberly Babiarz, PhD, Stanford University, Stanford, CA and Jeremy D. Goldhaber-Fiebert, PhD, Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, CA
Purpose: India has over 2 million new tuberculosis (TB) cases annually. In addition to causing serious death and disability, patients often sell assets, borrow money or reduce consumer spending to finance treatment or compensate for lost wages, jeopardizing household members’ health and financial stability. We quantify TB’s short- and long-term financial consequences, arguing that the full benefit of TB control policies should account for these effects. 

Method(s): We estimated TB’s short-term financial impact, analyzing household survey data (n=1,574) describing individuals who had initiated public sector TB treatment in Bihar, India. We assessed cost of consultations, medication, travel and total out-of-pocket costs using linear and quantile regressions, accounting for demographics and episodes of prior TB care. We estimated TB’s impact on socioeconomic status (SES) in the long-term (4 years and 7 years) using the Study on Global Ageing and Adult Health (SAGE) (waves 0 and 1; n=3703) and the India Human Development Survey (IHDS) (waves I and II; n=120,242), respectively. We first categorized households’ SES in quintiles relative to a national reference standard. We predicted how TB altered the probability of a household being in each SES quintile at follow-up conditional on the starting quintile, urban/rural status, and demographics using ordered logistic regressions.

Result(s): In the short-term, households of individuals with TB spend on average a total of 430 Rupees if they have not had prior episodes of TB care and 1,290 Rupees if they have. These costs represent 6% (no prior TB) and 19% (prior TB) of average total monthly household consumption expenditure for Bihar. Over the longer-term, TB-related costs or losses reduce the chance that households will improve their SES position. For example, a rural household falling in the middle SES quintile with a 20–29 year-old male TB patient has a 38% chance of moving to a higher SES quintile after 4 years, compared to 49% for a similar household without TB. This effect intensifies over time. After 7 years, the chance of improving SES is 33% for a household with TB versus 51% without. TB-induced reductions in upward mobility are more pronounced for poorer households.

Conclusion(s): TB traps many households in poverty. Evaluations of disease control policies should account for TB’s long-term health and financial implications for the entire household.

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