| BackgroundChina is currently one of the 22 countries with highest burden of tuberculosis with the number of PTB patient ranked No.2 all over the world.Based on the official disease control information website (http://202.106.123.35/).the cases of notification and death are always on the top among all infectious disease.Two-thirds of the new cases are aged from 15 to 54 years old with more than 80%in rural area,80%of the household with the net income per capita are less than that of local level. TB always occur in poverty populations,it is one of the main reasons that makes patients and households more poverty.TB epidemic situation in Hunan is severe.The incidence of smear positive tuberculosis was estimated to be 0.059%in 2004,and 28.3%higher than the average level in the nationwide.Every year more than 50,000 active pulmonary tuberculosis(PTB) are detected out and treated in the whole province, while 30,000 of them are infectious PTB.TB is the major infectious diseases that severely threatens the health and life of the people and brings heavy economic burden to the patient household and society.Since 1992,Chinese government has carried out the World Bank loan TB control program in sixteen provinces,extensively implemented the DOTS(directly observed treatment,short course) strategy,and had reached the global target of that at least 70%of incident smear-positive cases should be detected and treated in DOTS and that at least 85%of those cases should be successfully treated.In order to achieve the targets for MDG(Millennium development goal) global TB control,that TB prevalence and death rates should be halved by 2015 compared with their level in 1990,Chinese government are implementing and carrying out the Global TB control Strategy positively,including further strengthening the service system,expanding and improving the quality of DOTS,free charge of diagnosing and treating for PTB,coping with the challenge of TB/HIV co-infection,management of floating population TB,multi-drug resistant tuberculosis control and other special issues(poverty population, prison,school,and others),mobilizing patients,communities and whole society to take part in the TB control and ensuring the quality management and take the patient-oriented measures.To verify and evaluate the extent of government commitment,the economic burden of PTB should be evaluated and estimated based on the point of view of patient household,society and government respectively.Over the past decades,we have got some valuable explore on the economic study of TB,such as calculating the TB hospitalization expenditures using inpatient sample,computing the medical cost from the point of patients basing on the local health statistics yearbook,estimating DALY from the point of view of society to assess the TB burden. Different studies,different subjects and different methods lead to different results,and most of them focused on patients individual,There is no unified identification and measure method to assess the TB economic burden.In fact,the TB economic impacts to patient individual, household,government and society include not only the direct economic burden such as medical cost,fee for traffic,accommodating and nutrition, but also the fund such as government input to TB control and foreign aid TB program.loss of DALY due to disability and premature death,loss of income because of absence from work both of patient and his/her family members,decreasing the social wealth created by patient.Converting the loss of healthy life years into money should be a indispensable part of the study on disease economic burden.In addition,few study referred to the change of the household income and expenditure due to PTB.Assessing the PTB economic burden scientifically and comprehensively is valuable and significant for the government to make TB control strategy.Objectives1.To establish a frame to assess PTB economic burden,to lay the technical foundation for reseach of disease economic burden in the future.2.To Estimate and evaluate the PTB economic burden in Hunan Province by the way of PTB patient and household,government and society.To describe the current status and distribution characteristics of PTB economic burden.Analyses the extent and problems of the TB control implementation at government level.3.To investigate the impacts of PTB to patient individual and household,establish the disease burden index of PTB household.4.To analyses the main influencing factors to PTB economicburden.Explore approaches effective enough to relieve the economic burden for the patient household.5.To make some strategic suggestion for TB control based on the research results and the fact of our province.Methods1.Main study indications and the operational definition(1) PTB direct economic burden:total cost for prevention,treatment and recovery paid by patient family,government and society,including direct medical cost(clinic treatment,hospitalization,assistant tests,drugs, health care and recovery) and direct non-medical cost(fee for traffic, acommandation room and board and nutrition consummated by patient and accompany).①Patient household direct economic burden:the various fees and charges for the diagnosis and treatment of TB an d the rehabilitation process paid by family directly,including direct medical cost(clinic treatment,hospitalization,drugs,health care,etc.) and direct non-medical cost(fee for patients and companies traffic,room and board and nutrition).②Government direct economic burden:including direct medical cost offered by governments at all levels and other foreign aid TB control programme for free tests,diagnosis and anti-TB drugs for patients,and direct non-medical cost for TB health education,training,supervision, case-tracing,following up and visiting to patients,etc.③Total direct economic burden:the sum of patient household and government direct economic burden.(2) Indirect economic burden:refer to the economic burden due to disability or premature death,including absenteeism in workplace of patients individual and family members and loss of health life years. Converting the loss of time and life years into currency,quantitatively analysis the loss indirectly.①Family indirect economic burden:the loss of family production or income because of absence work or unemployed due to PTB both the patients and family members.②Society indirect economic burden:convert healthy life year into money,measure the loss of social wealth created by the patients due to disability or premature death indirectly.(3) PTB economic burden:the sum of direct and indirect social economic burden(4) The disease burden index of household(DBI):this is the creative new indication It is the ratio of the direct economic burden on household with the total household annual net income.DBI refers how many years' net income it will take for the patients' family to pay for the direct economic loss caused by the disease.The more the index is,the long time it will take to make up the loss.DBI could be used to not only PTB but also other diseases and could be compared between different diseases.2.Sources of data and methods(1) Field surveyUsing stratified cluster sampling,randomly choose two counties from national-level poverty support counties,provincial-level poverty support counties,and non-poverty counties respectively.They are Xiangtan and Shaodong(non-poverty),Shimen and Yongding(provincial-level poverty counties),and Pingjiang and Anhua(national-level poverty counties). Subjects are new active PTB patients in these six sample counties from July to September in 2005 with the age more than 15 years old.From the former research,the rate of being in sickbed(referring to disability) in PTB patients is 22.5%,the sample should be 345(basing on the formula:N=1.96~2×P(1-P) / D~2,δ=0.2P).Take into account of 15% dropping off and non-response,397 consecutive subjects should be involved in the project at least.Interview all the cases and family members with a structured questionnaire at the time of diagnosis and at the end of treatment duration respectively with the informed consent. Collecting data on patients' extent of disability due to PTB,process of diagnosis and treatment,medical cost,income and expenses both of patient and family members one year before and after being sick.Recruit all the new registered cases in the six counties,follow up one year,analyses the outcome.Estimating the DALY due to PTB respectively basing the death age and gender.(2) Statistical data sources:①The population,sex ratio,per capita net income,per capita GDP in the whole province and sample counties in 2005 and 2006 were got from Hunan Statistical Yearbook 2006 and 2007.②TB incidence in 2005 came from the WHO's annual report of TB control in 2007.③The registered cases and their outcome in the whole province and the six sample counties came from the quarterly report in TB control planning and information management system for TB in 2005-2006.④Census data in Hunan 2000 were used to be a standard population for the standard life expectancy table.⑤The numbers of funds offered by governments and other foreign aid TB programme were got from the Mid-term evaluation data of TB control planning(2001-2010) in Hunan Province and sample counties and the funds allocated schedule in the project implementation units all over the province.3.Main study content(1) PTB direct economic burden:①Family direct economic burden = direct medical cost + direct non-medical cost.The data and information is collected by interviewing the patients and family members from household by household.Estimating the classifying sum of the patient household direct economic burden and the average level.②Government direct economic burden = supporting funds from government for TB control + aided funds from foreign aid TB control programmes.Basing on the Mid-term evaluation data of TB control planning (2001-2010) in Hunan Province and sample counties,government funds invested on TB control was defined as the government direct economic burden in the project.③Social direct economic burden = Social direct economic burden per case×population×incidence of PTBSocial direct economic burden per case = household direct economic burden per case + government direct economic burden per case(2) PTB indirect economic burden:①Household indirect economic burden =(PTB patients absence work days + the family members absence from work days)×labour force income per dayUsing human capital method,basing on the number of absent work days both of patients and family members,converting the net income of local farmers to daily average labor income,estimating the family indirect economic burden.②Social indirect economic burden = DALYs×GDP×weight of productivitySocial loss of DALY = direct loss of DALY + indirect loss of DALYDirect loss of DALY:basing on the direct loss of DALY per case got from the survey sample,calculate the total direct DALY loss of all the registered and treated PTB cases in Hunan Province in 2005.Indirect loss of DALY:basing on the fatality and mean death age got from the early epidemiology studies(in the pre-drug era),calculating the annual loss of DALY,then basing on the average diagnostic delay days(time interval between the appearance of PTB symptoms and the first time to seeking health service),estimating the average indirect loss of DALY of the unregistered and undetected cases under the current DOTS,then assess the total indirect social loss of DALY of the unregistered cases in the province.Using human capital method and DALY,combining the weight of age for registered patients in the province and sample counties and local annual GDP per capita,we can get the total social indirect economic burden in the province.(3) PTB total social economic burden = direct social economic burden + indirect social economic burden.(4) Analyses the social economic influence of PTB to patients,in the aspects of daily life,extent of social function limitation,changes of patients' medical cost and income before and after being sick.Realize the financing methods of PTB direct economic burden and changing in household consumption patterns,Calculate the family burden of disease index(the ratio of the direct economic burden on patients' family with the total household annual net income).(5) Multivariate analysis on factors impacting the patient household economic burden from the points of social demography,severity of illness, utilization of medical service and economic income of patients and their families by ordinal logistic regression.4.Statistic AnalysisAll data derived from the questionnaires were processed using EpiData 3.0 and SPSS software package(version 11.0) for univariate analysis and multivariate analysis.Non-parametric tests were used when comparing means or proportions because of the asymmetric distributions of values.Statistic tables and charts were drawn from EXCEL(2003).Calculate DALY using formula of GBD and fixed values of parameters.Life expectancy were got from the standard life expectancy table in Hunan 2000.The value of disability was based on the GBD disability grade and its weight,and corrected properly by the life habits of rural residents and the characteristics of TB.Results1.Characteristics of the sample population: (1) A total of 354 PTB cases were recruited in the study with 258 male(72.9%) and 96 female(27.1%).The average age was 43.2±15.4 years old and the median of the education year was 9.66.9%of the subjects were first married,while 19.2%unmarried,6.8%remarried, 7.1%divorced or loss of spouse.The occupation of the patients were farmers(57.1%),working out(26.6%),commerce and service(10.2%) and unemployed and no fixed job(5.6%).Averagely there were 3.4 persons in a patient's family,1.95 of them are work force.91.3%of them were in the age group of 16-59 when it's the most productive.(2) Total of 3652 active PTB patients were registered and treated in the six sample counties in 2005 and cohort followed up for one year, 3349(91.7%) cases of them were successfully cured.156(4.3%) cases died with 76 for PTB and 80 for other diseases or reasons,the the fatality was 2.1%.122(3.3%) cases were default.11(0.3%) cases failed,while 14 were with other outcome.(3) Totally 47440 active PTB patients were registered in the whole province in 2005.The new register rate of PTB was 70.5/10~5,and the incidence rate of TB was 100/10~5.2.The direct economic burden due to PTB(1) The direct economic burden per household was 1459.8 yuan RMB,with the median 1045 RMB.While the direct medical cost per case was 1267.3 yuan RMB(median 902),and the non-medical cost was 192.6 yuan RMB(median 152).The total family direct economic burden in the whole province was 69 million yuan RMB.(2) The government direct economic burden per case was 927.9 yuan RMB.The funds offered by governments and foreign aided programmes were 44.02 million yuan RMB.(3) The social direct economic burden per case was 2387.7 yuan RMB,The total in the province was 161 million RMB. 3.The indirect economic burden due to PTB(1) The family indirect economic burden per case was 887.5 yuan RMB.The total in the whole province was 59.48 million yuan RMB.(2) The social indirect economic burden per case was 4409.1 yuan RMB.The total in the province was 297 million yuan RMB.4.The total economic burden due to PTB(1) The total economic burden on family per case was 2347.3 yuan RMB,while the total of the whole province was 129 million yuan RMB.(2) The total economic burden on government per case was 927.9 yuan RMB,while the total funds offered by governments and foreign aided programmes actually were 44.02 million yuan RMB(47 million yuan RMB planned).(3) The total economic burden on society per case was 6796.8 yuan RMB,while the total of the whole province was 458 million yuan RMB.5.The loss of DALY due to PTB(1) The average direct loss of DALY was 0.57 person-year,with the YLL 0.26 and YLD 0.31,while the total loss of DALY on society was 27,246 healthy-life years.(2) The average indirect loss of DALY was 0.88 person-year,with the total loss of DALY on society was 17,495 healthy-life years.(3) The total loss of DALY on society was 44,741 healthy-life years.(4) The loss rate of DALY all of the TB patients was 40.5/10~5 with male 58.0/10~5and female 21.1/10~5.6.The social and economic impacts of PTB to patient individual and household(1) The average duration of symptoms lasting was 118.8 days (median 98 days).The average absence work time was 95.7 days(median 93 days).The average absence work days of family members due to PTB was 8.2 days(median 5 days). (2) The ratio of household annual income reduction from 53.1%to 37.2%before and after being illness.The reduction of net income per case was 1700.6 RMB(median 1000 RMB) per case.(3) The proportion of per capita annual net income less than that of local level increased from 64.4%to 76%before and after being illness. Per capita annual revenue of household in 70.7%families was less than before being illness year.The average reduction of annual revenue of per household was 358.6 yuan RMB(median 200 RMB).(4) The proportion of household overspending the annual revenue was increased from 26.3%to 69.5%before and after being illness,with overspending per household of 429.2 yuan RMB(median 625 RMB).(5) Illness-related costs affected patients and their families.The direct economic burden for each household due to PTB amounted to 20.4%of annual household expenditure,and 89.6%of the family's total medial expenses.Of the patient household financing methods,63.8%of direct economic burden was most frequently financed from household savings (out of pocket),19.1%transfer payments from community members and relatives,6.2%of them offered by parents or children,5.8%sold part of their property and only 1%paid by medical insurance or new rural cooperative medical system.To cope with illness-related expenditures and income reductions,the patent household had to change the annual consumption patterns,including cutting down 16.4%of the living expenditure,and 4.6%expenses for cultural,educational,and recreational and communication,etc.7.The diseases burden index of household(DBI)The average DBI of PTB household was 0.33 years,and the median was 0.16 years(0.14-10.3).8.Factors impacting the family economic burdenOrdinal Logistic regression shows that factors significantly contributed to patient household economic burden are hospitalization (OR=423.266,95%CI 71.236-2514.929),a long lasting duration of PTB symptoms(OR=4.175,95%CI 2.519-6.917),a long duration of absence of work(OR=4.166,95%CI 1.203-14.426),3 times or more for encounter before diagnosis(OR=2.083,95%CI 1.261-3.442) and diagnostic delay(OR=2.610,95%CI 1.319-5.186)..while highly educated(OR=0.233,95%CI 0.069-0.786),high income of the patient(OR=0.431,95%CI 0.202-0.920) and visiting TB control agent directly when PTB symptoms onset(OR=0.140,95%CI 0.051-0.386) could alleviate the patient household economic burden.Significance and conclusionThis research established the frame for the study of PTB economic burden,basing on field survey and a great deal of epidemiologic data. Investigate the measurement of the economic burden and loss of health life year due to PTB and calculate the economic burden in Hunan Province from the viewpoint of patients,household,government and society.Using the standard lift expectancy in Hunan population,calculate the direct loss of DALY due to the all registered and treated PTB patients in the whole province.Assess the average social indirect loss of DALY of patients who were not been detected and found under the DOTS strategy implementation,basing on the average days of delay to diagnosis and the fatality and average death age of patients without treatment.To analyses the family economic loss due to PTB more accurately,a new indicator (DBI) was created to measure the illness-related economic loss of patient household,that is the ratio of patient househould direct economic burden due to TB with the annual revenue of household.Main conclusion are as follows:1.PTB brings heavy economic burden to patients,families, government and society.The economic loss to society is much greater than that to patients household for a period. 2.PTB not only lead to constraining of social functions to most of patients,but also loss 0.57 healthy-life year for each case.The disease reduces the income of patients and their families.It takes near 4 months annual revenue of patient household to make up the economic loss due to PTB,with the DBI of 0.33 year.To cope with illness-related expenditures and income reductions,the patients household have to cut down living and educational expenditure pattern.PTB makes about 70%of the patient household overspend the annual revenue and poor families become more impoverished.3.Free charge of TB medical service offered by government can relief the patient household burden at some extent,but it only cover the basic diagnostic items including sputum examination,X ray chest film and anti-TB drugs et al.the expenditure on liver function and kidney function tests before and after confirmed diagnosis,basic liver-protective agent and allopathic treatment,traffic,room and board is difficult to bear for the patient household.4.The responsibility is seems to lie with government rather than patients to alleviate their burden,government commitment should be further enhance.A long sustainable development plan and financing mechanism for TB control should be established urgently.If the patient household direct economic burden of patients after diagnosis(609.6 RMB per capita) is involved in free of charge,government level by level has to raise fund another 28.92 million RMB.5.The patient household economic burden is closely related to the health care provider.Strengthen the service system establishment and improve the quality of service is needed currently,so as to reduce the hospitalization expenditure and encounter times before the diagnosis. Improving the accessibility and availability of TB service among TB patients and their household is also a way to significantly reduce PTB economic burden.6.The medical security system for TB is not yet perfect,especially in rural countryside.Only a little TB inpatients who take part in the new rural cooperative medical system could get the allowance offered by government and the corresponding medical security,which take only 1% of the patient household direct economic burden.It is suggested that some illness-related expenditure of PTB should plan as a whole in currently health insurance system.Parts of expenditure including hospitalization and clinic not offered by government yet should be taken into the medical insurance and new rural cooperative medical system,and the free charge service items for TB patients and TB suspects should be enlarged and increased.
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