Impact of an innovative tuberculosis financing and payment model on health service utilization by tuberculosis patients in China:do the poor fare better than the rich?

Background:Tuberculosis(TB)prevalence is closely associated with poverty in China,and poor patients face more barriers to treatment.Using an insurance-based approach,the China-Gates TB program Phase II was implemented between 2012 and 2014 in three cities in China to improve access to TB care and reduce the financial burden on patients,particularly among the poor.This study aims to assess the program effects on service use,and its equity impact across different income groups.Methods:Data from 788 and 775 patients at baseline and final evaluation were available for analysis respectively.Inpatient and outpatient service utilization,treatment adherence,and patient satisfaction were assessed before and after the program,across different income groups(extreme poverty,moderate poverty and non-poverty),and in various program cities,using descriptive statistics and multi-variate regression models.Key stakeholder interviews were conducted to qualitatively evaluate program implementation and impacts.Results:After program implementation,the hospital admission rate increased more for the extreme poverty group(48.5 to 70.7%)and moderate poverty group(45.0 to 68.1%),compared to the non-poverty group(52.9 to 643%).The largest increase in the number of outpatient visits was also for the extreme poverty group(4.6 to 5.7).The proportion of patients with good medication adherence increased by 15 percentage points in the extreme poverty group and by ten percentage points in the other groups.Satisfaction rates were high in all groups.Qualitative feedback from stakeholders also suggested that increased reimbursement rates,easier reimbursement procedures,and allowance improved patients'service utilization.Implementation of case-based payment made service provision more compliant to clinical pathways.Conclusion:Patients in extreme or moderate poverty benefited more from the program compared to a non-poverty group,indicating improved equity in TB service access.The pro-poor design of the program provides important丨essons to other TB programs in China and other countries to better address TB care for the poor.

Impact of an innovative financing and payment model on tuberculosis patients'financial burden:is tuberculosis care more affordable for the poor?

Background:In response to the high financial burden of health services facing tuberculosis(TB)patients in China,the China-Gates TB project,PhaseⅡ,has implemented a new financing and payment model as an important component of the overall project in three cities in eastern,central and western China.The model focuses on increasing the reimbursement rate for TB patients and reforming provider payment methods by replacing fee-for-service with a case-based payment approach.This study investigated changes in out-of-pocket(OOP)health expenditure and the financial burden on TB patients before and after the interventions,with a focus on potential differential impacts on patients from different income groups.Methods:Three sample counties in each of the three prefectures:Zhenjiang,Yichang and Hanzhong were chosen as study sites.TB patients who started and completed treatment before,and during the intervention period,were randomly sampled and surveyed at the baseline in 2013 and final evaluation in 2015 respectively.OOP health expenditure and percentage of patients incurring catastrophic health expenditure(CHE)were calculated for different income groups.OLS regression and Iogit regression were conducted to explore the intervention's impacts on patient OOP health expenditure and financial burden after adjusting for other covariates.Key-informant interviews and focus group discussions were conducted to understand the reasons for any observed changes.Results:Data from 738(baseline)and 735(evaluation)patients were available for analysis.Patient mean OOP health expenditure increased from RMB 3576 to RMB 5791,and the percentage of patients incurring CHE also increased after intervention.The percentage increase in OOP health expenditure and the likelihood of incurring CHE were significantly lower for patients from the highest income group as compared to the lowest.Qualitative findings indicated that increased use of health services not covered by the standard package of the model was likely to have caused the increase in financial burden.Conclusions:The implementation of the new financing and payment model did not protect patients,especially those from the lowest income group,from financial difficulty,due partly to their increased use of health service.More financial resources should be mobilized to increase financial protection,particularly for poor patients,while cost containment strategies need to be developed and effectively implemented to improve the effective coverage of essential healthcare in China.

Experiences and challenges in the health protection of medical teams in the Chinese Ebola treatment center,Liberia:a qualitative study

Background:Health care workers are at the frontline in the fight against infectious disease,and as a result are at a high risk of infection.During the 2014-2015 Ebola outbreak in West Africa,many health care workers contracted Ebola,some fatally.However,no members of the Chinese Anti-Ebola medical team,deployed to provide vital medical care in Liberia were infected.This study aims to understand how this zero infection rate was achieved.Methods:Data was collected through 15 in-depth interviews with participants from the People’s Liberation Army of China medical team which operated the Chinese Ebola Treatment Center from October 2014 to January 2015 in Liberia.Data were analysed using systematic framework analysis.Results:This study found numerous bio-psycho-socio-behavioural risk factors that directly or indirectly threatened the health of the medical team working in the Chinese Ebola Treatment Center.These factors included social and emotional stress caused by:(1)the disruption of family and social networks;(2)adapting to a different culture;(3)and anxiety over social and political unrest in Liberia.Exposure to Ebola from patients and local co-workers,and the incorrect use of personal protective equipment due to fatigue was another major risk factor.Other risk factors identified were:(1)shortage of supplies;(2)lack of trained health personnel;(3)exposure to contaminated food and water;(4)and long working hours.Comprehensive efforts were taken throughout the mission to mitigate these factors.Every measure was taken to prevent the medical team’s exposure to the Ebola virus,and to provide the medical team with safe,comfortable working and living environments.There were many challenges in maintaining the health safety of the team,such as the limited capability of the emergency command system(the standardized approach to the command,control,and coordination of an emergency response),and the lack of comprehensive international protocols for dealing with emerging infectious disease pandemics.Conclusions:The comprehensive and multidisciplinary measures employed to protect the health of the medical team proved successful even in Liberia’s resource-limited setting.The global health community can learn valuable lessons from this experience which could improve the safety of health care workers in future emergencies.These lessons include:establishing capable command systems;implementing effective coordination mechanisms;providing adequate equipment;providing training for medical teams;investing in the development of global health professionals;and improving research on ways to protect health care workers.

Are tuberculosis patients adherent to prescribed treatments in China? Results of a prospective cohort study

Background:Tuberculosis(TB)patients face numerous difficulties adhering to the long-term,rigorous TB treatment regimen.Findings on TB patients’treatment adherence vary across existing literature and official reports.The present study attempted to determine the actual treatment adherence of new TB patients and to identify factors leading to non-adherence.Methods:A prospective cohort of 481 newly confirmed TB patients from three counties in western China were enrolled during June to December 2012 and was followed until June 2013.Patients who missed at least one dose of drugs or one follow-up re-examination during the treatment course were deemed as non-adherent.Influencing factors were identified using a logistic regression model.Results:A total of 173(36.0%)patients experienced non-adherence and the loss to follow-up cases reached 136(28.2%).Only 13.9%of patients took drugs under direct observation,and 60.5%of patients were supervised by phone calls.Factor analyses suggested that patients who were observed by family members(OR:5.54,95%CI:2.87–10.69)and paying monthly service expenses above 450 RMB(OR:2.08,95%CI:1.35–3.19)were more likely to be non-adherent,while supervision by home visit(OR:0.06,95%CI:0.01–0.28)and phone calls(OR:0.27,95%CI:0.17–0.44)were protective factors.Conclusions:Despite recent efforts,a large proportion of newly confirmed TB patients could not adhere to standard TB treatment,and patients’lost to follow-up was still a serious problem.Poor treatment supervision and heavy financial burden might be the main causes for non-adherence.More needs to be done to enhance treatment supervision policies and financial supports to both health providers and TB patients.

Impacts of a comprehensive tuberculosis control model on the quality of clinical services and the financial burden of treatment for patients with drug-resistant tuberculosis in China:a mixed-methods evaluation

Background:The China National Health Commission-GatesTB Project Phase III implemented a comprehensive TB control model including multiple interventions to address the burden of drug-resistant TB(DRTB).This study aims to evaluate the quality of DRTB clinical services and assess the financial burden of DRTB patients during the intervention period.

The impact of increased reimbursement rates under the new cooperative medical scheme on the financial burden of tuberculosis patients

Background:Tuberculosis(TB)is still a major public health problem in China.To scale up TB control,an innovative programme entitled the'China-Gates Foundation Collaboration on TB Control in China was initiated in 2009.During the second phase of the project,a policy of increased reimbursement rates under the New Cooperative Medical Scheme(NCMS)was implemented.In this paper,we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data.Methods:In two cross-sectional surveys,quantitative data were collected before(January 2010 to December 2012)and after(April 2014 to June 2015)the intervention in the existing NCMS routine data system.Information on all 313 TB inpatients,among which 117 inpatients in the project was collected.Qualitative data collection included 11 focus group discussions.Three main indicators,non-reimbursable expenses rate(NER),effective reimbursement rate(ERR),and out-of-pocket payment(OOP)as a percentage of per capita household income,were used to measure the impact of intervention by comprising post-intervention data with baseline data.The quantitative data were analysed by descriptive analysis and non-parametric tests(Mann-Whitney U test)using SPSS 22.0,and qualitative data were subjected to thematic framework analysis using NvivolO.Results:The nominal reimbursement rates for inpatient care were no less than 80%for services within the package.Total inpatient expenses greatly increased,with an average growth rate of 11.3%.For all TB inpatients,the ERR for inpatient care increased from 52 to 66%.Compared with inpatients outside the project,for inpatients covered by the new policy,the ERR was higher(78%),and OOP showed a sharper decline.In addition,their financial burden decreased significantly.Conclusions:Although the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy,inpatient OOP expenditure was still a major financial problem for patients.Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement.Comprehensive control models are needed to effeaively decrease the financial burden on all TB patients.

Is tuberculosis patients management improved in the integrated TB control model in West China?A survey in Guizhou Province,China

Background:Tuberculosis(TB)patient management(TPM)is crucial to improve patient compliance to treatment.The coverage of TPM delivered by TB dispensaries or Centers for Disease Control and Prevention(CDC)was not high under the previous CDC model of TB control in China.In the integrated TB control model in China,TB patient management(TPM)was mainly delivered by lay health workers(LHWs)in primary health care(PHC)sectors.This study aims to investigate TPM delivery in resource-limited western China and to identify factors affecting TPM delivery by LHWs under the integrated TB control model.Methods:A stratified random sampling was used to select study sites.Pulmonary TB(PTB)patients≥15 years old from selected counties/districts in Guizhou Province were surveyed from August 2015 to May 2016.Structured questionnaires were used to collect data.Aχ^2 test and logistic regression were used to identify factors associated with self-administered treatment(non-TPM).Results:In total,638 PTB patients were included in the final analysis.Close to 30%of patients were ethnic minorities.More than 30%of patients were from counties with high TB burden,and 24.9%of patients had poor compliance to treatment.Only 37.1%of patients received TPM delivered by LHWs under the integrated TB control model throughout the treatment period.The main reasons for unwillingness to manage reported by patients included social stigma and no perceived need.Being ethnic minorities(OR=3.35)was a main factor associated with lower likelihood of receiving TPM,while living in areas with middle or high TB burden may increase the likelihood of receiving TPM(OR=0.17 and 0.25,respectively).Among current management approaches,more than 85%of patients chose phone reminder as their preferred TPM by LHWs.Conclusions:TPM under the integrated model in West China is still low and need further improvement,and the impeding factors of TPM need to be addressed.Strengthening patient-centered and community-based TPM and developing more feasible approaches of TPM delivery should be explored in future research in this region.

Access to quality diagnosis and rational treatment for tuberculosis: real-world evidenee from China-Gates Tuberculosis Control Project Phase Ⅲ

Background:China has successfully reduced tuberculosis(TB)incidence rate over the past three decades,however,challenges remain in improving the quality ofTB diagnosis and treatment.I n this paper,we assess the effects of the implementation of"China National Health Commission(NHC)and Gates Foundation TB Preventi on and Control Pro-jectwon the quality ofTB care in the three provinces.

Process evaluation of E-learning in continuing medical education:evidence from the China-Gates Foundation Tuberculosis Control Program

Background:E-learning is a growing phenomenon which provides a unique opportunity to address the challenges in continuing medical education(CME).The China-Gates Foundation Tuberculosis(TB)Control Program implemented online training forTB health workers in three provinces of China.We aim to evaluate the implementation of E-learning CME programs,analyse the barriers and facilitators during the implementation process,and to provide policy recommendations.

Impact of multiple policy interventions on the screening and diagnosis of drug-resistant tuberculosis patients:a cascade analysis on six prefectures in China

Background:The detection of drug-resistant tuberculosis(DR-TB)is a major health concern in China.We aim to summarize interventions related to the screening and detection of DR-TB in Jiangsu Province,analyse their impact,and highlight policy implications for improving the prevention and control of DR-TB.Methods:We selected six prefectures from south,central and no「th Jiangsu Province.We reviewed policy documents between 2008 and 2019,and extracted routineTB patient registration data from theTB Information Management System(TBIMS)between 2013 and 2019.We used the High-quality Health System Framework to structure the analysis.We performed statistical analysis and logistic regression to assess the impact of different policy interventions on DR-TB detection.Results:Three prefectures in Jiangsu introduced DR-TB related interventions between 2008 and 2010 in partnership with the Global Fund to Fight AIDS,Tuberculosis and Malaria(the Global Fund)and the Bill&Melinda Gates Foundation(Gates Foundation).By 2017,all prefectures in Jiangsu had implemented provincial level DR-TB policies,such as use of rapid molecular tests(RMT),and expanded drug susceptibility testing(DST)for populations at risk of DR-TB.The percentage of pulmonary TB cases con firmed by bacteriology in creased from 30.0%in 2013 to over 50.0%in all prefectures by 2019,indicating that the implementation of new diagnostics has provided more sensitive testing results than the traditional smear microscopy.At the same time,the proportion of bacteriologically confirmed cases tested for drug resistance has increased substantially,indicating that the intervention of expanding the coverage of DST has reached more of the population at risk of DR-TB.Prefectures that implemented interventions with support from the Global Fund and the Gates Foundation had better detection performance of DR-TB patiens compared to those did not receive external support.However,the disparities in DR-TB detection across prefectures significantly narrowed after the implementation of provincial DR-TB polices.Con elusions:The introduction of new diagnostics,including RMT,have improved the detection of DR-TB.Prefectures that received support from the Global Fund and the Gates Foundation had better detection of DR-TB.Additionally,the implementation of provincial DR-TB polices led to improvements in the detection of DR-TB across all prefectures.

The effectiveness of E-learning in continuing medical education for tuberculosis health workers: a quasi-experiment from China

Background:Given the context of rapid technological cha nge and COIVD-19 pan demies,E-lear ning may provide a unique opportunity for addressing the challenges in traditional face-to-face continuing medical education(CME).However,the effectiveness of E-learning in CME interventions remains unclear.This study aims to evaluate whether E-learning training program can improve TB health personnel's knowledge and behaviour in China.

Implementing a new tuberculosis surveillance system in Zhejiang,Jilin and Ningxia:improvements,challenges and implications for China’s National Health Information System

Background:China is still faced with the public health challenge of tuberculosis(TB),and a robust surveillance system is critical for developing evidence-based TB control policies.The Tuberculosis Information Management System(TBIMS),an independent system launched in 2005,has encountered several challenges in meeting the current needs ofTB control.The Chinese government also planned to establish the National Health Information System(NHIS)aggregating data in different areas.The China National Health Commission-Gates TB Project Phase III launched a new TB surveillance system to address these challenges and also as a pilot for the countrywide implementation of the NHIS.This commentary highlights the improvements and challenges in implementing the newTB system and also discusses the implications for the roll-out of the NHIS.