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What lessons can de drawn from tuberculosis (TB) Control in China in the 1990s?
Health Policy 72 (2005) 93–104
What lessons can de drawn from tuberculosis (TB) Control in China in the 1990s? An analysis from a health system perspective Shenglan Tanga,∗ , Stephen Bertel Squireb a
International Health Research Group of Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK b Clinical Research Group of Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
Abstract China has made a significant achievement in tackling the TB epidemic over the last decade, due largely to the implementation of directly-observed treatment strategy (DOT). The cure rate of TB cases reached more than 90% for registered TB patients. However, the case detection rate has, unfortunately, been very low (some 30%). Using available information, this paper identifies four main problems facing TB control in China, these are, low case finding, a substantial proportion of TB patients failing to complete standardised treatment, increased proportion of MDR TB patients, and lack of effective TB control among “floating populations”. The paper also analyses the possible causes of these problems associated with socio-economic barriers in care seeking, ineffectiveness of TB services, particularly in poor areas, lack of co-operation between health facilities, and weakness of political and financial commitments of local governments to TB control. The paper ends with the discussion of opportunities and challenges facing TB control and makes recommendations for further actions and research. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: TB control; Health system; China
1. Background China is faced with a serious epidemic of tuberculosis. There are over 5 million people with active TB and it is the leading infectious cause of mortality, resulting in 130,000 deaths annually. According to the nationwide TB epidemiological survey in 2000, about 550 million Chinese people are infected with Mycobac∗ Corresponding author. Tel.: +44 151 7053197; fax: +44 151 7053364. E-mail address: [email protected] (S. Tang).
terium tuberculosis, of which 10% may develop TB clinically during their lives. Although, there are effective preventive measures available to stop these infected people from developing TB, it is not practical to do so in China with such a large TB-infected population. Treating infectious TB patients (i.e. smear-positive TB patients) has been regarded as the most effective way to control TB in China. In 1991, the National TB Control Programme developed a 10-year programme with the aim to halve the TB prevalence by 2000. Two projects, the Infectious and Endemic Disease Control (IEDC) Project supported by a World Bank loan and the Min-
0168-8510/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2004.06.009
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istry of Health supported TB Control Project, were initiated in 1992 and 1993, respectively. These initiatives introduced the WHO ‘directly observed treatment short course’ (DOTS) strategy, comprising the five elements of government commitment, infectious case detection using smear microscopy, directly-observed standardised short-course chemotherapy, uninterrupted supply of TB drugs and an effective monitoring system. The IECD project covered some 560 million people and provided smear-positive TB patients with free treatment when they sought care in the TB dispensaries across the project counties. The MoH project covered around 136 million people and provided financially subsidised treatment to those smear-positive TB patients identified in the project counties. After one decade of implementation of the DOTS strategy in many parts of China and the treatment of several million TB patients, the national TB prevalence rates have come down, albeit slowly [1]. Due to the growth of the Chinese population, the estimated number of smearpositive TB patients in fact rose slightly from 1990 to 2002 [2,3], according to the nationwide TB epidemiologic surveys. The most recent survey also found that the TB case detection rate still remain very low (about 30%). Therefore, there is a great challenge facing the Chinese government in TB control and prevention for many years to come. This paper aims to analyse what has been achieved in TB control over the past decade and what have been the main problems that hindered the Chinese government in implementing effective TB control and their possible causes. The paper particularly tries to analyse these problems from a health system perspective. Additionally, it is hoped that the paper will provide Chinese policy-makers and international organisations involved in TB control with recommendations, and offer researchers in China and elsewhere suggestions on future research directions on TB control in China. The data used in the paper come from a variety of sources including nationwide TB epidemiological surveys, published and unpublished TB research reports, journal articles in Chinese and English, and personal communications with a number of leading TB experts in China and health professionals responsible for TB control and prevention at provincial and district levels. The paper first introduces briefly the reform of the health care system and its impact on health service delivery since the economic reform launched
in China in the late 1970s. It then summarise the achievements in TB control and discusses the main problems related to access, particularly of the poor, to TB care and the effective treatment of TB patients, and analyses possible factors causing these problems in China over the past decade. It ends with a discussion of opportunities and challenges in TB control and suggestions and recommendations on effective TB control for the next decade in China. The paper is not expected to illustrate in detail the achievements made in TB control; these have already been published the Chinese and English literature [4]. 2. Reform of health care system and analysis of its impact on service delivery From the foundation of the People’s Republic of China to the economic reform launched in the late 1970s, the Chinese Communist Party and its government placed health care as one of its top priorities. Over the first three decades of the new People’s Republic, the provision of basic health care, particularly in relation to the control of infectious diseases, such as sexually transmitted disease (STD) and TB, was high on the government agenda. In the rural areas of China, a so-called three-tier network of health care was well developed by the 1970s. In other words, a large number of health facilities at county, township and village levels were established to provide a variety of health services to local people (Fig. 1). TB-related services were usually available at county general hospitals, county dispensaries and township health centres1 . In the meantime, with the support of the central government, most of the rural townships and villages in China developed cooperative medical schemes (CMS), covering over 90% of the Chinese rural population by the end of the 1970s [14]. Rural CMS are prepayment schemes which can provide financial support (often as reimbursements of medical care expenditures incurred) to the participants of the scheme when they seek care at designated health facilities. Participants are required to pay a premium for their participation. Local governments and/or local 1 In some counties, the county TB dispensary is part of County Anti-Epidemic Station which has been recently called the Centre for Disease Control and Prevention (CDC). In addition, many township health centres, particularly in the poor rural areas, are providing limited TB-related services to local people.
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Fig. 1. Structure of county health sector in rural China.
collectives in many places subsidised these schemes financially. In addition, all the health facilities located in the rural areas of China received a grant from the finance department of local governments, which allowed them to set up service prices at a level lower than real operational costs. As a result, the vast majority of the rural population in China was able to access basic health care at a low cost during the 1960s and 1970s. In urban China, two work-related health insurance schemes (Government Insurance Scheme and Labour Insurance Scheme) were developed in the early 1950s, respectively, to cover the employees from the public sector, and workers from manufacturers and enterprises [14]. These two schemes, together with the government health grants given to urban health facilities as financial subsidy, have helped a majority of the urban Chinese population to enjoy almost free health care until the 1980s. Since the late 1970s, China has been transforming its planned economy to a market-oriented economy. Rural agricultural production was de facto privatised in the early 1980s. The rural collective economy, which used to be strong and supported the rural CMS before the end of 1970s, has been greatly weakened or disappeared in most townships and villages. As a consequence, the CMS collapsed in most of the rural areas by the mid1980s. Schemes, which once took care of over 90% of the rural population, covered less than 10% of the rural population in the 1990s. Meanwhile, financing of health facilities in China has also changed significantly. The government health
grants given to these facilities has become less important, since the health grants, as a percentage of total income of health facilities, has increasingly declined to a low level (less than 10% in most publicly funded health facilities). In other words, these health facilities have had to rely on user fees to cover their operation costs. Even preventive health institutions, such as AntiEpidemic Station and Maternal and Child Health Centres, have to raise revenues via user fees to cover part of their operational costs, although they are supposed to be fully funded by the government. Under such circumstances, user fees have become the most important source of revenue for almost all Chinese health facilities. A similar situation happened in urban China where the reform of the two work-related health insurance schemes resulted in few people being covered. Service users, even those covered by insurance schemes are required to pay out of pocket for medical care through excess (deductible) and co-insurance payments, for example. While the hospitals and other health facilities in both urban and rural areas have to generate revenue to support their operations, the managers of these facilities have also been given greater autonomy to decide what kind of health services they would like to provide and how to allocate their financial resources. They have used bonus systems to encourage their health workers to generate more revenues for their hospitals and health centres. All these changes have induced many detrimental changes in medical care, such as irrational prescription of drugs for profits by doctors. It is not sur-
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Fig. 2. Sources of income for health facilities in China.
prising, therefore, that these health facilities have been developing a variety of means to attract patients in order to generate more revenues by providing more services and selling more drugs (Fig. 2). It is also common to see that, the more revenues a health worker generated, the higher bonus s/he could be awarded. Such a problem, created by a perverse incentive, has implications not only for quality and cost of health care, but also for equity in access to health care among vulnerable groups [13,14].
3. Achievements in TB control over the 1990s There have been several significant achievements in TB control observed in China over the past decade. The IEDC project jointly funded by the World Bank and the Chinese government, and the MoH supported TB control project, have been an impetus leading TB control. A number of key achievements made in tackling the TB epidemic are as follows: According to the official figures, the IEDC project provided some 9 million TB suspects with free diagnostic services. In the project county areas, about 2 million TB patients were diagnosed, of which 1.62 million TB patients (1.46 million smear-positive TB patients plus 0.16 million severe smear-negative TB patients) were treated free of charge at the county TB dispensaries [3]. Over 90% of smear-positive TB patients treated were cured. During the implementation of the DOTS strategy, the percentage of previously treated cases among
all smear-positive cases decreased and treatment outcomes improved greatly [4]. As a result of the project implementation, the smear-positive TB prevalence rate reduced about 44.4% in the IEDC project areas between 1990 and 2000, while the prevalence rate decreased only 12.3% in the non-IEDC project areas over the same period [2,3]. Over the past decade, the IEDC project and the MoH supported TB control project have organised a series of training workshops across the country, providing technical and managerial training related to TB control and prevention. Several thousands of health professionals responsible for TB control and prevention have upgraded their knowledge and skills; vital to the effective implementation of TB control. TB experts from national and provincial levels have developed a number of manuals and protocols related to TB control issues, such as diagnosis, treatment and case management. In addition, the two projects, particularly the IEDC project, have been able to provide financial resource to develop infrastructure for TB control institutions, especially at the county level in the project areas. Better quality buildings and more modern equipment have been seen in the TB dispensaries in many rural areas. The quality of TB services has to a large extent been improved in the project areas. The TB control projects have also made a great effort to increase the awareness of TB among the public and local political leadership via extensive health education and other means. A wider constituency, which includes provincial and county governors, village leaders and health workers
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and villagers, have now understood the seriousness of the TB epidemic compared with 10 years ago2 . Additionally, political and financial commitments made by the central and local governments have been strengthened over the past 3–5 years in China. The central government has decided to allocate 40 million Chinese Yuan each year as a special fund against TB. Many provincial and municipal governments have also allocated adequate funds to support TB control projects. Relatively rich municipal governments such as Shanghai and Shengzhen have developed a policy that all TB patients diagnosed by any health facilities and managed by the TB dispensaries in the cities, regardless of their residential status (i.e. both official residents and rural migrants), should receive free treatment. Such a policy is likely to be extended to the whole country soon. In other words, all smear-positive TB patients, and serious smear-negative TB patients would be provided free treatment, as long as they have registered with TB dispensaries in the cities where they are living. Due to the above-mentioned achievements, the national TB control programme in China has been regarded by many international organisations as a successful model [5].
4. Problems jeopardising effective TB control and their causes There are a number of problems that have affected the effectiveness of TB control in China over the past decade. The first is a low case detection (case-finding) rate. As a whole, the case detection rate in China was probably around 30%, according to the 2000 survey3 . In the IEDC project areas, the detection rate for new smear-positive cases was estimated to be 54% in 1998. This implies that there is a large pool of infectious TB patients across the country who may not get diagnosed and treated adequately and in a timely manner, and thus continue to suffer due to the disease, and con2 This has been reflected in the report of the IEDC project evaluation submitted by the MoH to the World Bank in 2002. 3 It is not easy to get an accurate figure for case detection rate based on a cross-section survey. Those patients who were not diagnosed before the survey, but were diagnosed as TB patients during the survey might eventually have been diagnosed when their symptoms became more serious and prompted further care seeking from health providers, even if they had not been sampled to participate in the survey.
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tinue to pose a risk of infecting their family members, colleagues and other members of society. In addition, a substantial proportion of TB patients whose sputum tests were negative were often left out of the TB control projects. The second main problem is an overall lack of quality in TB health care provision. For example, over 70% of TB patients in China, most of whom did not register with county TB dispensaries, were estimated to fail to complete standardised treatments, according to the national TB patients sampling survey [6]. For TB patients registering with and treated by the TB dispensaries, only 61% of them received the recommended standardised anti-TB treatment. As for the TB patients treated by general hospitals and not registering with the TB dispensaries, only 21% of them received the recommended standardised anti-TB treatment. This problem may have contributed to the third main problem, which is the development of multi-drug resistance (MDR). The nationwide TB epidemiological survey conducted in 2002 showed that the MDR rate among the new TB patients was 7.6%, while the rate was as high as 17.1% among relapse TB cases. The estimated global average MDR rate for new TB cases was only 3.2% in 2000 [19]. The fourth main problem is the difficulty of handling the increased number of TB patients who are rural migrants (often called “floating population) working and living in the urban areas, since they are usually living in poor conditions (e.g. crowded houses) and they often lack medical insurance and earn less money than urban residents. They move from one place to another and the municipal TB control centres have faced a great challenge in treating and monitoring those rural migrants suffering from TB. This problem may have also contributed to the above-mentioned three problems. According to a report from Minhang district of Shanghai, 125 of its 460,000 rural migrants (or 27.2 per 100,000 population) in the district were diagnosed with TB during the period of January–July 2002. The rate was higher than that of ordinary residents of the district (140 of its 640,000 ordinary residents or 21.9 per 100,000 population)4 . However, only 4 TB case detection rate in the rural migrants would have to be much higher than that of ordinary residents in Minhang district, if the rate had been age-adjusted, as it is understood that the rural migrants working in large cities in China tend to be young.
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16 rural migrant TB patients have registered with the district TB dispensary and received adequate treatment. We may assume that the rest of rural migrant TB patients may have gone back to their home towns or remained in the district without being treated or have been treated elsewhere. Although the policy of the Shanghai Municipal Government is to provide free treatment to these rural migrants through the district TB dispensary, the implementation of the policy has not so far been effective, for various reasons discussed below. Many Chinese and international organisations and experts involved in TB control in China have a clear understanding of these main problems affecting TB control in China. However, the root causes of these problems may not be fully recognised and understood. The rest of this section analyses and discusses possible causes of these problems in order to develop effective solutions. The analysis of causes of the problems reflects the importance of the factors. 4.1. Barriers in access to health care There are a number of barriers faced by a majority of the Chinese population, and particularly the rural poor, in seeking health care. In 2000, about 65% of the Chinese people are living in the rural areas, but less than 10% of the rural population, most of whom are in the rich areas (such as rural Shanghai and Jiangsu), are covered by a variety of rural CMS. In other words, the majority of the Chinese rural population have to pay for health care out of their pockets. Of 1340 TB patients found in the nationwide TB epidemiologic survey, less than 10% of them had health insurance of any kind. In the recent years, the costs of medical care have risen dramatically. Fang [7] reported in his Ph.D. study that the total financial costs (direct and indirect) borne by a new TB patient in the course of care seeking could be as high as between 0.67 and 1.99 times their average annual income in different areas of China. The total costs to an average relapse TB patient could be as high as between 1.96 and 2.63 times their average annual income. The survey also found that about 35% of TB patients did not have any occupationalrelated incomes. As a result of this, an increased number of TB patients have financial difficulties seeking essential health care. In addition, those rural migrants
working and living in the urban areas are also in a disadvantaged position in access to health care, because they are less likely to be covered by any medical insurance. In the IEDC project areas, the policy states that smear-positive TB patients should be provided with free treatment. In addition, they can also get reimbursement for all expenditures incurred in taking diagnostic tests. However, people suffering from TB in the project counties could benefit from these concessions and entitlements, only if they sought TB care at appropriate county TB dispensaries. If they sought TB-related care at county general hospitals or township health centres, they had to pay for all the diagnostic tests and treatments without prospects for reimbursement. According to the socio-economic part of the nationwide TB epidemiologic survey in 2002, less than 20% of TB patients in the project areas were estimated to be treated in the TB dispensaries. This implies that even in the IEDC project areas, less than 20% of the TB patients obtained free treatments and were eligible for reimbursements of their expenditures related to TB diagnostic tests (the percentage of smear-positive TB patients being given free treatment must be much higher, since the project only targeted smear-positive TB patients). Even more surprisingly, according to some studies conducted in some of the project provinces, such as Shandong, some county TB dispensaries actually did not follow the policies of providing free treatment to smear-positive patients [8,9]. They still charged some fee for the drugs they provided to these TB patients. They also asked these TB patients to take unnecessary diagnostic tests in order to generate more revenue for their own health facilities. The health managers from these TB dispensaries reported that, since they failed to get a matching fund for the IEDC project which their local governments had promised before the project started, charging TB patients was the only way to recoup the costs of the project operation. This may be partially true. In Wanzhou district of Chongqing where the IEDC project was implemented in the 1990s, the authors found that the district TB dispensaries tended to extend the TB standard treatment from 6 months to up to 9–12 months for new TB patients. The IEDC project only provided 6 months free treatment. The patients had to pay for the extended treatment themselves. Local chest physicians explained that the extended treatment aimed to ensure that the treatment would be successfully com-
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pleted and relapse TB cases could be avoided in the future. This may be part of the reason behind the decision. However, another factor that has probably led to this happening is the way in which the income of health workers is linked with the amount of revenue they generate in China’s health sector, as discussed in the previous section. Social stigma is another barrier that prevents TB suspects from seeking timely and appropriate care. Young people, particularly young women would have difficulties finding a partner and getting married, if they were known to their communities as TB patients. Dorf [10] reported that the husbands in inner Mongolia might divorce their wives if they found out their wives suffer from TB for the fear that they themselves and their children may be affected. Rural migrants working in the service section of urban areas would lose their jobs, if found to suffer from TB. Hence, it is not uncommon for these people to delay in seeking health care. In addition, the awareness of TB as a serious disease among the public is also very low. A research report commissioned by the Department for International Development, UK shows that the public and TB patients lack TB-related knowledge. Health workers provided patients with very limited information during medical consultations [11]. A National Health Service survey reported that Chinese people from the poor areas were less likely to self-report illness because they thought chronic cough, having sputum, etc. were not abnormal [12]. The socio-economic part of the nationwide TB epidemiological survey in 2002 found that only about half of people with TB-related symptoms sought health care [6]. Meng et al. [8] found that the TB patients in the low income group took on average 4 days longer in seeking health care after the appearance of TB-related symptoms than those TB patients in the middle income group. The percentage of low-income patients seeking health care within 14 days after the appearance of TB-related symptoms was about 10% lower than that of middle and high income patients. The reasons for not seeking care or delay in seeking care can be complex. Among them may be financial difficulty (lack of income and medical insurance, e.g.), social stigma and lack of necessary knowledge about TB symptoms (which may be associated with the education level of the patients) and the availability of free care, as well as the age of the patients.
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4.2. Lack of quality in TB health care TB health services refer to TB-related diagnostic tests and treatments, as well as relevant preventive services. In rural China, most people usually seek health care at village health stations, private clinics and township health centres [12]. Unfortunately, most health workers at the village health stations, private clinics at the village and township levels, and even at the township health centres, have low levels of qualifications. There is also lack of necessary medical equipment in these health facilities to provide TB-related diagnosis services or tests. In some township health centres, there may be microscopes to undertake sputum tests. However, as reported by health managers from a district in Jinan city, Shandong province, most of these microscopes were too old to be properly functioning. Of course, the health workers at these facilities could refer TB suspects to higher-level health facilities, such as county TB dispensaries or county general hospitals. However, two main reasons might prevent them from doing so. One is that they might not have sufficient skills and experiences to identify TB suspects. The other is that they might want to keep these patients at their own facilities and treat them as common patients suffering from cold/flu or other diseases in order to make money from the services and the drugs they sold to them. As a consequence, even those TB patients who did seek care from health providers failed to get diagnosed as TB cases. Using the data from the nationwide TB epidemiological survey, Wang et al. [6] reported that about 40% of the TB patients found in the survey had sought health care (mostly at the village and township levels), but had not been diagnosed as TB cases. The new policy developed by the national TB control programme in China requires the township health centres and village health stations to refer all TB suspects to their county TB dispensaries. Whether or not this new policy can help improve case detection rate needs to be evaluated in due course. Poor quality of TB treatment is another big problem, particularly in the areas where there were no effective TB control projects supported by the Chinese government and donors. It may be true that the TB cure rate among TB patients who have registered with the county TB dispensaries, particularly in the IECD project areas, has been as high as over 90%. However, the completion rate of TB treatment in the whole of China may
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not be as high as has been reported in many official reports. According to the nationwide TB epidemiological study, only one-quarter of 374 TB patients were receiving standardised treatment at the time the survey was conducted. The rest of TB patients either ceased the treatment before the course was complete or received intermittent treatments. Zhang [11] reported that TB patients in the poor areas usually could not complete the full course of their treatment due largely to their poor financial situation. Meng et al. [8] found that onethird of total TB-related medical care was incurred by patients before getting diagnosed as TB cases. In other words, a substantial amount of money was spent prior to achieving a TB diagnosis. Many TB patients were then not able to find any money to pay for appropriate treatments thereafter. There are many factors affecting failure to complete TB treatment. Some health professionals responsible for TB control reported that the side effects emanating from taking these drugs were one of the most important reasons why some TB patients stopped their treatments. However, the nationwide TB epidemiological survey showed that only 4.8% of TB patients ceased treatment or had intermittent treatment, owing to the side effects of the drugs. In addition, the directly observed treatment approach has been used in many parts of China. Usually, village health workers (rural doctors) are the persons responsible for observing the TB patients to take the drugs. Drugs may be sometimes kept at the village health stations and the TB patients are required to go to the village health stations to take the drugs once a day. As reported in Shandong Province where the IEDC project was implemented in 1992–1999, these village health workers were paid 30–40 Yuan (US$ 4–5) for each TB patients they cared for. It is said that DOT using village health workers as observers was not very successful in some places. The reasons include the following: (a) each village health worker on average only took care of up to three to four TB patients and they were not interested to earn such a small amount of money for a relatively long period; and (b) most TB patients, especially those living in remote or mountainous areas, were reluctant to visit the village health stations every day to take the drugs. Therefore, in most occasions, the village health workers, after several weeks of initial treatment, allowed the patients to take the drugs back to their home and asked one of patient’s family member as an observer. These patients usually visited
the village health stations once a month to take the bulk of the drugs back home. In the evaluation of IEDC projects there are several main problems related to the treatment of TB patients. First, the percentage of TB patients managed by TB dispensaries was very low. Those TB patients treated by general hospitals may have received different treatment regimes, some of which might not be effective. Second, controlling TB among the floating population has increasingly been difficult. There have so far been no practical measures for targeting rural migrants who fall ill with TB. Third, the capacity of TB service delivery, particularly in the poor rural areas, is not adequate, which has affected the effectiveness of TB control over the past decade. The final problem is that a majority of smear-negative TB patients have not been appropriately treated, even in the IEDC project areas, due largely to lack of resources. According to the estimates made by some Chinese leading TB experts, half of smear-negative patients may become smear-positive after a 5-year period, often due to irregular treatment, which may give rise to MDR. They then may infect other people in their communities. 4.3. Lack of co-operation and co-ordination between health facilities Lack of co-operation and co-ordination between health facilities in fighting TB is one of the greatest weaknesses in implementing TB control and prevention effectively in China. As discussed previously, the Chinese hospitals and other health facilities are stateowned and can therefore be called public hospitals or public health facilities. Nevertheless, they have been maximising profits through service provision and drug sales [13,14]. This is due partly to a relative decline of government funding given to support these preventive health facilities since the economic reform. Therefore, managers and directors of health facilities have now become more conscious of operational costs and profit making. According to the nationwide TB epidemiological survey conducted in 2002, over 80% of TB patients were diagnosed at general hospitals, rather than TB dispensaries. Doctors in these general hospitals who detected TB patients are obliged to report these cases to the county TB dispensary, according to the Infectious Disease Prevention and Treatment Law. In reality, however, only 15% of the TB patients diagnosed at
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general hospitals were registered with TB dispensaries [6]. In addition, in the IEDC project areas, smearpositive TB patients were entitled to enjoy free treatment and reimbursement of the expenditure related to TB diagnostic services. However, doctors at the general hospitals, due to their vested financial interest, tended not to tell the TB patients this information. Nor did they tend to refer them to the county TB dispensary. As a consequence of this, TB patients, and particularly the poor, ended up paying for all TB-related services out of pocket; a financial burden that should have been avoided. Such a problem in the implementation of health legislation and regulations is not uncommon in China since the introduction of the market economy. Tang [15] found that many health facilities, especially in the poor areas, have selectively implemented health legislations and regulations. When health facilities and health workers realised that certain health legislation can bring benefits to them, they have an incentive to implement it effectively and actively. When health legislation has negative implications for their financial interest, they tend to ignore it. The health sector reform undertaken in China has given the managers of health facilities more power and autonomy to do what they want to do, which has produced some negative impacts on TB control. Such a situation is also found in Kenya and in Zambia where the introduction of health sector reform may have brought about more difficulties and challenges to effective disease control programmes [16,17]. 4.4. Political and financial commitments of local governments Political and financial commitments of both central and local governments are vital to the effectiveness of TB control. In China, once the central government has made its political and financial commitments, it tends to honour them. However, this may not be the case with many local governments, especially at the county level of the poor areas. For example, in the IEDC project areas, local governments at provincial, prefecture/municipal and county levels, were required to provide a certain amount of so-called matching funds to co-finance the project. In fact, the project county governments only provided 56% of the committed funds during the project period. In Gansu province, one of the
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poorest provinces in China, the actual matching fund provided by the county government accounted for only 35.5% of the funds committed. As much research has shown, the fiscal status of county governments in the poor areas is often very poor. Once they have paid the salaries of their employees, little money is left for funding the social services for which they are supposed to take responsibility [18]. Failure to provide matching funds committed to the TB control project has jeopardised the implementation of the project. It is understood that some county governments in the poor areas were under pressure to commit themselves to allocate a certain amount of matching fund which they knew the county government would have formidable difficulties honouring. Such a failure to providing the matching funds has to some extent contributed to some county TB dispensaries’ over charging TB patients for diagnostic services and treatments. TB control projects in China only provided county TB dispensaries with necessary drugs and equipment. However, the costs of TB control operation at the county TB dispensaries, such as transportation, travel subsistence, maintenance and other consumable materials were supposed to be covered by a grant given by the county finance bureau. In the poor areas such a grant given to the TB dispensaries by the county governments has not been able to compensate for the rapid rise in operational costs, which is due largely to wage inflation, among other factors. The effective management of TB cases has come at a price. One district health manager responsible for TB control from Shandong province illustrated this point by stating that the more you have done for TB control projects, the heavier the financial burden your institution had to bear, since the county government health grant or the project budget given to the TB dispensary has usually been fixed at the beginning of the project. Meng et al. [8] found that the TB dispensaries in Shandong, like their counterparts in other provinces, tried to provide other services (e.g. treatment of STDs) that can generate revenues for their institutions. Zhan et al. [9] also found out that some TB dispensaries asked TB patients to take unnecessary X-ray examinations every month in order to generate revenues. Both inadequate government funding for TB control and perverse incentives to the health staff (i.e. getting more bonuses through generating revenue) are responsible for such behaviours.
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The above analysis of possible causes of the main problems related to effective TB control and prevention in China over the past decade also illustrates to some extent the limitations and constraints of implementing the DOTS strategy in many parts of China. Several DOTS elements, such as supply of TB drugs and central government commitment, have been successfully implemented in China, while other DOTS elements have not yet been effectively implemented in some parts of China, and particularly in the poor areas. The analysis and discussion presented above also reveals that most of the main problems associated with ineffectiveness of TB control can be attributed to weaknesses in the Chinese health care system.
5. Opportunities and challenges for next decade TB control and prevention has in recent years been a top priority for the Chinese government with the support of many international organisations. After the completion of the IEDC project, the World Bank, working with the Department for International Development, UK, has helped the Chinese government to develop a new large TB control project with over US$ 200 million, covering 16 provinces (most of which are poor provinces) and almost half of the Chinese population. In 2002, the Global Fund against HIV/AIDS, TB and Malaria offered a large grant of US$ 48 million for TB control in China. CIDA, Canada has also recently approved over one million dollars for TB control in three provinces of China (Shandong, Jiangsu and Zhejiang). JICA and Damian Foundation, Belgium, as well as WHO WPRO, have also been supporting TB control and prevention in China. Besides all this international support, the central Chinese government and an increasing number of local governments in China have committed extra funds for fighting TB in the recent years. All this political and financial support is an excellent opportunity for China to build upon what it has done in TB control and continue to tackle the TB epidemic and poverty in a more effective way. In addition, the IEDC project and the MoH supported TB control projects, as described above, have provided many lessons and experiences for future TB control in China. The continuation of good practices should be promoted, while attention should be paid to
the lessons learnt from the previous projects in developing new projects. Furthermore, good practices and lessons from other developing countries have also been available to China via the technical support from the WHO as well as international collaboration through a variety of international organisations. While China has a historical opportunity to fight TB, there are also many challenges facing such a tough war against this great public health and social problem. Low case detection rate (case finding) is the most important challenge facing the effectiveness of TB control and prevention in China, as pointed out by Chen et al. [4]. Whether or not China can develop a series of robust measures to increase the case finding is a key to the success of TB control in the near future. It is essential and imperative for the Chinese central and local governments as well as international communities to pool financial resources for fighting TB in China. But, while financial resources are necessary, they are not sufficient in ensuring that all these TB control projects mentioned above will be effectively implemented. Human and physical/infrastructure capacities are also very vital to the success of implementing these projects in the next decade. Challenges for the poorer areas of China are how to get good project managers and TB experts to deliver the expected outputs and outcomes that the Chinese governments and international communities want to see with the huge amount of financial resources committed. The development of rational mechanisms of financing all the health facilities responsible for TB control and prevention is also very important. Tackling financing mechanisms is central to ensuring that general hospitals, particularly at the county level, are willing to co-operate with county TB dispensaries in the operation of referring, reporting, case management, and monitoring. Without good co-operation between these health facilities, the effective implementation of these TB control projects in China may be in a great jeopardy. The remuneration of health staff responsible for TB treatment and prevention in all types of facilities needs to be properly addressed and dealt with. Public health workers’ income should not be linked to the quantity of the revenue they generate through charging patients for TBrelated services they provide. All this needs a reform of the current Chinese health care system so that TB control can develop in a healthy and sustainable fashion.
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6. Suggestions and recommendations This section offers some recommendations on developing more robust TB control measures and on the areas for further research towards effective TB control in China. Each recommendation is presented in order of priority. The expansion of DOTS implementation to the whole country should be put as a top priority in the years to come, since the benefits of successful DOTS implementation in many parts of China have been demonstrated over the past decade. Particular efforts should be made to improve and strengthen the implementation of some DOTS elements that have blocked the speedy reduction of TB prevalence rates in some areas of China. Policy-makers and health professionals should be aware that the expansion of DOTS implementation may not automatically result in national TB control programme reaching the poor, a key element for an increase in case detection rate. It is also very important to mobilise political support from local governments, particularly in the poor areas. Local politicians and government bureaucrats should be made aware of TB being not only a serious public health problem, but also a social problem. They should also pay special attention to TB control in their areas. One important action that the national TB control programme should take in the near future is to develop proactive approaches to TB case finding. One approach could be the establishment of a community-based TB surveillance system, using trained village health workers. Village health workers in the areas of high TB prevalence rates could be trained to identity TB suspects proactively and refer them to the county TB dispensary, probably via township health centres, for chest X-ray fluoroscopy and sputum tests. Monthly regular meetings with these village health workers could be organised at the township health centres to discuss TB-related matters, among others. They should be financially adequately awarded, regardless of whether or not the TB suspects they refer are found smear positive, provided that their performance has been appropriate. Action research (via pilot studies) needs to be considered to test new strategies and approaches that can be more effective in improving case finding in the poor areas where the TB notification rates have been low. These strategies and approaches should be based on the assessment of po-
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litical, financial, cultural and administrative feasibility. Information, Education and Communication (IEC) in relation to TB care should be widely available to the public. By developing an appropriate IEC strategy and implementing it effectively, the national TB control projects should aim to achieve several specific objectives. The first is to increase the awareness of the TB epidemic among the public and the leadership at different levels of local government. The public needs to be provided information and education on TB and its implication for the health of individuals, households and communities, as well as financial burden associated with untreated TB. The fact that TB is treatable should be a central part of these campaigns in order to tackle stigma. Secondly, the public needs to know government policies on fighting TB, e.g. smear-positive TB patients can get free diagnosis and treatment, via newspapers and TB adverts, etc. To achieve this, the TB control projects being implemented should allocate adequate budgets to publicise the policies of this kind by a variety of means. In addition, to develop effective means of publicising the message that TB is curable in order to reduce stigma would have to be an important part of such work to avoid imposing negative social consequences on those identified as TB cases. Research should be done to identify which means is most effective in communicating with the public. Appropriate financial mechanisms should be developed to ensure that TB control projects, especially in the poor areas are well resourced. It is inappropriate for the TB control projects to require county governments, and even prefecture governments, in poor areas to provide matching funds to support the TB control projects being implemented in their areas. Moreover, the poor who suffer from TB should not only be provided free diagnosis and treatment, but also given some financial support to cover indirect costs associated with TB treatment through medical financial assistance schemes. TB case management in China, as a whole, has not been functioning well, because of lack of co-operation between general hospitals and TB dispensaries. The proportion of TB patients who register with TB dispensaries has been extremely low, since physicians at the general hospitals have disincentives to refer their TB patients to the TB dispensaries. They do not even tend to report TB cases as required by the Infectious Disease Prevention and Treatment Law. Adequate in-
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centives could be investigated and developed to ensure that the regulations are effectively implemented. In the meantime, vigorous administrative intervention for better co-operation in TB case management between health facilities should be imposed across the country. Appropriate means for discipline, if necessary, should be taken against those doctors and hospitals violating the law. As a whole, it is vitally important to explore appropriate approaches to engaging hospitals and other health facilities in the implementation of DOTS. In the short term, TB control in China faces formidable barriers to success without a wider health system engagement in the implementation of DOTS expansion, and a focus on quality service delivery for the poor.
Acknowledgements The authors of the paper would like to express their sincere appreciation to many people, particularly Zhao Fengzeng, Wang Lixia, Wang Xuejing, Zhou Jiqian, Gong Youlong, Meng Qingyue, Li Renzhong, Zhang Tuohong, Zhan Shaokang, Jiang Xiwen and Daniel Chin who have generously spent their valuable time to discuss issues and problems related to TB control in China, and shared their TB-related research materials and experiences with us. Comments from Rachel Tolhurst, Wang Xuejing and others are highly valued and appreciated. The EQUI-TB Knowledge Programme based at the Liverpool School of Tropical Medicine and funded by DFID has been supporting the research on TB control in China.
References [1] Qian YF. Situation of TB epidemic is still very serious. TB Health Education 2000;1:36–7. [2] Ministry of Health of PR China. Report on nationwide random survey for the epidemiology of tuberculosis in 1990. China: Ministry of Health; 1991. [3] Ministry of Health of PR China. Report on nationwide random survey for the epidemiology of tuberculosis in 2000. China: Ministry of Health; 2002.
[4] Chen X, Zhao F, Duanmu H, Wan L, Wang L, Du X, et al. The DOTS strategy in China: results and lessons after 10 years. Bulletin of the World Health Organisation 2002;80(6):430– 6. [5] Hopewell P. Tuberculosis control: how the world has changed since 1990. Bulletin of World Health Organisation 2002;80(6):427. [6] Wang L, et al. A report on social assessment on TB patients. In the report on nationwide random survey for epidemiology of tuberculosis in 2000. [7] Fang JY. An economic evaluation of alternative projects for TB control and assessing the efficiency of TB control strategies by using mathematic models in China. Ph.D. thesis. Shanghai: Shanghai Medical University; 1999. [8] Meng Q, Li R, Cheng G. Impact of health funding decentralisation on access to TB care of the poor in Shandong province, China. Research report submitted to TDR SEB Health Sector Reform Project of WHO, Geneva; 2002. [9] Zhan SK, et al. Comparative analysis of three models for antiTB services: a case study in China. Report submitted to TDR SEB of WHO; 2003. [10] Dorf C. Consultant report on gender and tuberculosis control in inner Mongolia, China. Submitted to Damian Foundation, Belgium; 2003. [11] Zhang TH. Report on health staff/patient interaction and interpersonal relationship in poor areas of China. A consultant report submitted to DFID China; 2002. [12] Ministry of Health of P.R. China. Report on national health service survey in 1998. China: Ministry of Health; 1999. [13] Chen J, Bloom G, Wilkes A. The impact of China’s health sector reform on county hospital. World Hospitals and Health Services 1997;33(1):1091–8. [14] Gu X, Tang S. Reform of the Chinese health care financing system. Health policy, vol. 32 (1–3); 1995. Also included in Berman P, Editor. Health sector reform in developing countries: making health development sustainable. Harvard University Press; 1995. [15] Tang S. Health legislation in China: do the words matter? International Digest of Health Legislation 1999;50(2). [16] Hanson C, Kibuga D. Effective tuberculosis control and health sector reforms in Kenya: challenges of an increasing tuberculosis burden and opportunities through reform. International Journal of Tuberculosis and Lung Diseases 2000;4(7):627– 32. [17] Bosman MC. Health sector reform and tuberculosis control: the case of Zambia. International Journal of Tuberculosis and Lung Diseases 2000;4(7):606–14. [18] Zuo XJ. China’s fiscal decentralisation and financing local services in poor township. IDS Bulletin, vol. 28 (1). UK: Brighton; 1997. p. 81–91. [19] Espinal MA. The global situation of MDR-TB. Tuberculosis 2003;83:15–51.
What lessons can de drawn from tuberculosis (TB) Control in China in the 1990s? An analysis from a health system perspective Shenglan Tanga,∗ , Stephen Bertel Squireb a
International Health Research Group of Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK b Clinical Research Group of Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
Abstract China has made a significant achievement in tackling the TB epidemic over the last decade, due largely to the implementation of directly-observed treatment strategy (DOT). The cure rate of TB cases reached more than 90% for registered TB patients. However, the case detection rate has, unfortunately, been very low (some 30%). Using available information, this paper identifies four main problems facing TB control in China, these are, low case finding, a substantial proportion of TB patients failing to complete standardised treatment, increased proportion of MDR TB patients, and lack of effective TB control among “floating populations”. The paper also analyses the possible causes of these problems associated with socio-economic barriers in care seeking, ineffectiveness of TB services, particularly in poor areas, lack of co-operation between health facilities, and weakness of political and financial commitments of local governments to TB control. The paper ends with the discussion of opportunities and challenges facing TB control and makes recommendations for further actions and research. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: TB control; Health system; China
1. Background China is faced with a serious epidemic of tuberculosis. There are over 5 million people with active TB and it is the leading infectious cause of mortality, resulting in 130,000 deaths annually. According to the nationwide TB epidemiological survey in 2000, about 550 million Chinese people are infected with Mycobac∗ Corresponding author. Tel.: +44 151 7053197; fax: +44 151 7053364. E-mail address: [email protected] (S. Tang).
terium tuberculosis, of which 10% may develop TB clinically during their lives. Although, there are effective preventive measures available to stop these infected people from developing TB, it is not practical to do so in China with such a large TB-infected population. Treating infectious TB patients (i.e. smear-positive TB patients) has been regarded as the most effective way to control TB in China. In 1991, the National TB Control Programme developed a 10-year programme with the aim to halve the TB prevalence by 2000. Two projects, the Infectious and Endemic Disease Control (IEDC) Project supported by a World Bank loan and the Min-
0168-8510/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2004.06.009
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istry of Health supported TB Control Project, were initiated in 1992 and 1993, respectively. These initiatives introduced the WHO ‘directly observed treatment short course’ (DOTS) strategy, comprising the five elements of government commitment, infectious case detection using smear microscopy, directly-observed standardised short-course chemotherapy, uninterrupted supply of TB drugs and an effective monitoring system. The IECD project covered some 560 million people and provided smear-positive TB patients with free treatment when they sought care in the TB dispensaries across the project counties. The MoH project covered around 136 million people and provided financially subsidised treatment to those smear-positive TB patients identified in the project counties. After one decade of implementation of the DOTS strategy in many parts of China and the treatment of several million TB patients, the national TB prevalence rates have come down, albeit slowly [1]. Due to the growth of the Chinese population, the estimated number of smearpositive TB patients in fact rose slightly from 1990 to 2002 [2,3], according to the nationwide TB epidemiologic surveys. The most recent survey also found that the TB case detection rate still remain very low (about 30%). Therefore, there is a great challenge facing the Chinese government in TB control and prevention for many years to come. This paper aims to analyse what has been achieved in TB control over the past decade and what have been the main problems that hindered the Chinese government in implementing effective TB control and their possible causes. The paper particularly tries to analyse these problems from a health system perspective. Additionally, it is hoped that the paper will provide Chinese policy-makers and international organisations involved in TB control with recommendations, and offer researchers in China and elsewhere suggestions on future research directions on TB control in China. The data used in the paper come from a variety of sources including nationwide TB epidemiological surveys, published and unpublished TB research reports, journal articles in Chinese and English, and personal communications with a number of leading TB experts in China and health professionals responsible for TB control and prevention at provincial and district levels. The paper first introduces briefly the reform of the health care system and its impact on health service delivery since the economic reform launched
in China in the late 1970s. It then summarise the achievements in TB control and discusses the main problems related to access, particularly of the poor, to TB care and the effective treatment of TB patients, and analyses possible factors causing these problems in China over the past decade. It ends with a discussion of opportunities and challenges in TB control and suggestions and recommendations on effective TB control for the next decade in China. The paper is not expected to illustrate in detail the achievements made in TB control; these have already been published the Chinese and English literature [4]. 2. Reform of health care system and analysis of its impact on service delivery From the foundation of the People’s Republic of China to the economic reform launched in the late 1970s, the Chinese Communist Party and its government placed health care as one of its top priorities. Over the first three decades of the new People’s Republic, the provision of basic health care, particularly in relation to the control of infectious diseases, such as sexually transmitted disease (STD) and TB, was high on the government agenda. In the rural areas of China, a so-called three-tier network of health care was well developed by the 1970s. In other words, a large number of health facilities at county, township and village levels were established to provide a variety of health services to local people (Fig. 1). TB-related services were usually available at county general hospitals, county dispensaries and township health centres1 . In the meantime, with the support of the central government, most of the rural townships and villages in China developed cooperative medical schemes (CMS), covering over 90% of the Chinese rural population by the end of the 1970s [14]. Rural CMS are prepayment schemes which can provide financial support (often as reimbursements of medical care expenditures incurred) to the participants of the scheme when they seek care at designated health facilities. Participants are required to pay a premium for their participation. Local governments and/or local 1 In some counties, the county TB dispensary is part of County Anti-Epidemic Station which has been recently called the Centre for Disease Control and Prevention (CDC). In addition, many township health centres, particularly in the poor rural areas, are providing limited TB-related services to local people.
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Fig. 1. Structure of county health sector in rural China.
collectives in many places subsidised these schemes financially. In addition, all the health facilities located in the rural areas of China received a grant from the finance department of local governments, which allowed them to set up service prices at a level lower than real operational costs. As a result, the vast majority of the rural population in China was able to access basic health care at a low cost during the 1960s and 1970s. In urban China, two work-related health insurance schemes (Government Insurance Scheme and Labour Insurance Scheme) were developed in the early 1950s, respectively, to cover the employees from the public sector, and workers from manufacturers and enterprises [14]. These two schemes, together with the government health grants given to urban health facilities as financial subsidy, have helped a majority of the urban Chinese population to enjoy almost free health care until the 1980s. Since the late 1970s, China has been transforming its planned economy to a market-oriented economy. Rural agricultural production was de facto privatised in the early 1980s. The rural collective economy, which used to be strong and supported the rural CMS before the end of 1970s, has been greatly weakened or disappeared in most townships and villages. As a consequence, the CMS collapsed in most of the rural areas by the mid1980s. Schemes, which once took care of over 90% of the rural population, covered less than 10% of the rural population in the 1990s. Meanwhile, financing of health facilities in China has also changed significantly. The government health
grants given to these facilities has become less important, since the health grants, as a percentage of total income of health facilities, has increasingly declined to a low level (less than 10% in most publicly funded health facilities). In other words, these health facilities have had to rely on user fees to cover their operation costs. Even preventive health institutions, such as AntiEpidemic Station and Maternal and Child Health Centres, have to raise revenues via user fees to cover part of their operational costs, although they are supposed to be fully funded by the government. Under such circumstances, user fees have become the most important source of revenue for almost all Chinese health facilities. A similar situation happened in urban China where the reform of the two work-related health insurance schemes resulted in few people being covered. Service users, even those covered by insurance schemes are required to pay out of pocket for medical care through excess (deductible) and co-insurance payments, for example. While the hospitals and other health facilities in both urban and rural areas have to generate revenue to support their operations, the managers of these facilities have also been given greater autonomy to decide what kind of health services they would like to provide and how to allocate their financial resources. They have used bonus systems to encourage their health workers to generate more revenues for their hospitals and health centres. All these changes have induced many detrimental changes in medical care, such as irrational prescription of drugs for profits by doctors. It is not sur-
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Fig. 2. Sources of income for health facilities in China.
prising, therefore, that these health facilities have been developing a variety of means to attract patients in order to generate more revenues by providing more services and selling more drugs (Fig. 2). It is also common to see that, the more revenues a health worker generated, the higher bonus s/he could be awarded. Such a problem, created by a perverse incentive, has implications not only for quality and cost of health care, but also for equity in access to health care among vulnerable groups [13,14].
3. Achievements in TB control over the 1990s There have been several significant achievements in TB control observed in China over the past decade. The IEDC project jointly funded by the World Bank and the Chinese government, and the MoH supported TB control project, have been an impetus leading TB control. A number of key achievements made in tackling the TB epidemic are as follows: According to the official figures, the IEDC project provided some 9 million TB suspects with free diagnostic services. In the project county areas, about 2 million TB patients were diagnosed, of which 1.62 million TB patients (1.46 million smear-positive TB patients plus 0.16 million severe smear-negative TB patients) were treated free of charge at the county TB dispensaries [3]. Over 90% of smear-positive TB patients treated were cured. During the implementation of the DOTS strategy, the percentage of previously treated cases among
all smear-positive cases decreased and treatment outcomes improved greatly [4]. As a result of the project implementation, the smear-positive TB prevalence rate reduced about 44.4% in the IEDC project areas between 1990 and 2000, while the prevalence rate decreased only 12.3% in the non-IEDC project areas over the same period [2,3]. Over the past decade, the IEDC project and the MoH supported TB control project have organised a series of training workshops across the country, providing technical and managerial training related to TB control and prevention. Several thousands of health professionals responsible for TB control and prevention have upgraded their knowledge and skills; vital to the effective implementation of TB control. TB experts from national and provincial levels have developed a number of manuals and protocols related to TB control issues, such as diagnosis, treatment and case management. In addition, the two projects, particularly the IEDC project, have been able to provide financial resource to develop infrastructure for TB control institutions, especially at the county level in the project areas. Better quality buildings and more modern equipment have been seen in the TB dispensaries in many rural areas. The quality of TB services has to a large extent been improved in the project areas. The TB control projects have also made a great effort to increase the awareness of TB among the public and local political leadership via extensive health education and other means. A wider constituency, which includes provincial and county governors, village leaders and health workers
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and villagers, have now understood the seriousness of the TB epidemic compared with 10 years ago2 . Additionally, political and financial commitments made by the central and local governments have been strengthened over the past 3–5 years in China. The central government has decided to allocate 40 million Chinese Yuan each year as a special fund against TB. Many provincial and municipal governments have also allocated adequate funds to support TB control projects. Relatively rich municipal governments such as Shanghai and Shengzhen have developed a policy that all TB patients diagnosed by any health facilities and managed by the TB dispensaries in the cities, regardless of their residential status (i.e. both official residents and rural migrants), should receive free treatment. Such a policy is likely to be extended to the whole country soon. In other words, all smear-positive TB patients, and serious smear-negative TB patients would be provided free treatment, as long as they have registered with TB dispensaries in the cities where they are living. Due to the above-mentioned achievements, the national TB control programme in China has been regarded by many international organisations as a successful model [5].
4. Problems jeopardising effective TB control and their causes There are a number of problems that have affected the effectiveness of TB control in China over the past decade. The first is a low case detection (case-finding) rate. As a whole, the case detection rate in China was probably around 30%, according to the 2000 survey3 . In the IEDC project areas, the detection rate for new smear-positive cases was estimated to be 54% in 1998. This implies that there is a large pool of infectious TB patients across the country who may not get diagnosed and treated adequately and in a timely manner, and thus continue to suffer due to the disease, and con2 This has been reflected in the report of the IEDC project evaluation submitted by the MoH to the World Bank in 2002. 3 It is not easy to get an accurate figure for case detection rate based on a cross-section survey. Those patients who were not diagnosed before the survey, but were diagnosed as TB patients during the survey might eventually have been diagnosed when their symptoms became more serious and prompted further care seeking from health providers, even if they had not been sampled to participate in the survey.
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tinue to pose a risk of infecting their family members, colleagues and other members of society. In addition, a substantial proportion of TB patients whose sputum tests were negative were often left out of the TB control projects. The second main problem is an overall lack of quality in TB health care provision. For example, over 70% of TB patients in China, most of whom did not register with county TB dispensaries, were estimated to fail to complete standardised treatments, according to the national TB patients sampling survey [6]. For TB patients registering with and treated by the TB dispensaries, only 61% of them received the recommended standardised anti-TB treatment. As for the TB patients treated by general hospitals and not registering with the TB dispensaries, only 21% of them received the recommended standardised anti-TB treatment. This problem may have contributed to the third main problem, which is the development of multi-drug resistance (MDR). The nationwide TB epidemiological survey conducted in 2002 showed that the MDR rate among the new TB patients was 7.6%, while the rate was as high as 17.1% among relapse TB cases. The estimated global average MDR rate for new TB cases was only 3.2% in 2000 [19]. The fourth main problem is the difficulty of handling the increased number of TB patients who are rural migrants (often called “floating population) working and living in the urban areas, since they are usually living in poor conditions (e.g. crowded houses) and they often lack medical insurance and earn less money than urban residents. They move from one place to another and the municipal TB control centres have faced a great challenge in treating and monitoring those rural migrants suffering from TB. This problem may have also contributed to the above-mentioned three problems. According to a report from Minhang district of Shanghai, 125 of its 460,000 rural migrants (or 27.2 per 100,000 population) in the district were diagnosed with TB during the period of January–July 2002. The rate was higher than that of ordinary residents of the district (140 of its 640,000 ordinary residents or 21.9 per 100,000 population)4 . However, only 4 TB case detection rate in the rural migrants would have to be much higher than that of ordinary residents in Minhang district, if the rate had been age-adjusted, as it is understood that the rural migrants working in large cities in China tend to be young.
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16 rural migrant TB patients have registered with the district TB dispensary and received adequate treatment. We may assume that the rest of rural migrant TB patients may have gone back to their home towns or remained in the district without being treated or have been treated elsewhere. Although the policy of the Shanghai Municipal Government is to provide free treatment to these rural migrants through the district TB dispensary, the implementation of the policy has not so far been effective, for various reasons discussed below. Many Chinese and international organisations and experts involved in TB control in China have a clear understanding of these main problems affecting TB control in China. However, the root causes of these problems may not be fully recognised and understood. The rest of this section analyses and discusses possible causes of these problems in order to develop effective solutions. The analysis of causes of the problems reflects the importance of the factors. 4.1. Barriers in access to health care There are a number of barriers faced by a majority of the Chinese population, and particularly the rural poor, in seeking health care. In 2000, about 65% of the Chinese people are living in the rural areas, but less than 10% of the rural population, most of whom are in the rich areas (such as rural Shanghai and Jiangsu), are covered by a variety of rural CMS. In other words, the majority of the Chinese rural population have to pay for health care out of their pockets. Of 1340 TB patients found in the nationwide TB epidemiologic survey, less than 10% of them had health insurance of any kind. In the recent years, the costs of medical care have risen dramatically. Fang [7] reported in his Ph.D. study that the total financial costs (direct and indirect) borne by a new TB patient in the course of care seeking could be as high as between 0.67 and 1.99 times their average annual income in different areas of China. The total costs to an average relapse TB patient could be as high as between 1.96 and 2.63 times their average annual income. The survey also found that about 35% of TB patients did not have any occupationalrelated incomes. As a result of this, an increased number of TB patients have financial difficulties seeking essential health care. In addition, those rural migrants
working and living in the urban areas are also in a disadvantaged position in access to health care, because they are less likely to be covered by any medical insurance. In the IEDC project areas, the policy states that smear-positive TB patients should be provided with free treatment. In addition, they can also get reimbursement for all expenditures incurred in taking diagnostic tests. However, people suffering from TB in the project counties could benefit from these concessions and entitlements, only if they sought TB care at appropriate county TB dispensaries. If they sought TB-related care at county general hospitals or township health centres, they had to pay for all the diagnostic tests and treatments without prospects for reimbursement. According to the socio-economic part of the nationwide TB epidemiologic survey in 2002, less than 20% of TB patients in the project areas were estimated to be treated in the TB dispensaries. This implies that even in the IEDC project areas, less than 20% of the TB patients obtained free treatments and were eligible for reimbursements of their expenditures related to TB diagnostic tests (the percentage of smear-positive TB patients being given free treatment must be much higher, since the project only targeted smear-positive TB patients). Even more surprisingly, according to some studies conducted in some of the project provinces, such as Shandong, some county TB dispensaries actually did not follow the policies of providing free treatment to smear-positive patients [8,9]. They still charged some fee for the drugs they provided to these TB patients. They also asked these TB patients to take unnecessary diagnostic tests in order to generate more revenue for their own health facilities. The health managers from these TB dispensaries reported that, since they failed to get a matching fund for the IEDC project which their local governments had promised before the project started, charging TB patients was the only way to recoup the costs of the project operation. This may be partially true. In Wanzhou district of Chongqing where the IEDC project was implemented in the 1990s, the authors found that the district TB dispensaries tended to extend the TB standard treatment from 6 months to up to 9–12 months for new TB patients. The IEDC project only provided 6 months free treatment. The patients had to pay for the extended treatment themselves. Local chest physicians explained that the extended treatment aimed to ensure that the treatment would be successfully com-
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pleted and relapse TB cases could be avoided in the future. This may be part of the reason behind the decision. However, another factor that has probably led to this happening is the way in which the income of health workers is linked with the amount of revenue they generate in China’s health sector, as discussed in the previous section. Social stigma is another barrier that prevents TB suspects from seeking timely and appropriate care. Young people, particularly young women would have difficulties finding a partner and getting married, if they were known to their communities as TB patients. Dorf [10] reported that the husbands in inner Mongolia might divorce their wives if they found out their wives suffer from TB for the fear that they themselves and their children may be affected. Rural migrants working in the service section of urban areas would lose their jobs, if found to suffer from TB. Hence, it is not uncommon for these people to delay in seeking health care. In addition, the awareness of TB as a serious disease among the public is also very low. A research report commissioned by the Department for International Development, UK shows that the public and TB patients lack TB-related knowledge. Health workers provided patients with very limited information during medical consultations [11]. A National Health Service survey reported that Chinese people from the poor areas were less likely to self-report illness because they thought chronic cough, having sputum, etc. were not abnormal [12]. The socio-economic part of the nationwide TB epidemiological survey in 2002 found that only about half of people with TB-related symptoms sought health care [6]. Meng et al. [8] found that the TB patients in the low income group took on average 4 days longer in seeking health care after the appearance of TB-related symptoms than those TB patients in the middle income group. The percentage of low-income patients seeking health care within 14 days after the appearance of TB-related symptoms was about 10% lower than that of middle and high income patients. The reasons for not seeking care or delay in seeking care can be complex. Among them may be financial difficulty (lack of income and medical insurance, e.g.), social stigma and lack of necessary knowledge about TB symptoms (which may be associated with the education level of the patients) and the availability of free care, as well as the age of the patients.
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4.2. Lack of quality in TB health care TB health services refer to TB-related diagnostic tests and treatments, as well as relevant preventive services. In rural China, most people usually seek health care at village health stations, private clinics and township health centres [12]. Unfortunately, most health workers at the village health stations, private clinics at the village and township levels, and even at the township health centres, have low levels of qualifications. There is also lack of necessary medical equipment in these health facilities to provide TB-related diagnosis services or tests. In some township health centres, there may be microscopes to undertake sputum tests. However, as reported by health managers from a district in Jinan city, Shandong province, most of these microscopes were too old to be properly functioning. Of course, the health workers at these facilities could refer TB suspects to higher-level health facilities, such as county TB dispensaries or county general hospitals. However, two main reasons might prevent them from doing so. One is that they might not have sufficient skills and experiences to identify TB suspects. The other is that they might want to keep these patients at their own facilities and treat them as common patients suffering from cold/flu or other diseases in order to make money from the services and the drugs they sold to them. As a consequence, even those TB patients who did seek care from health providers failed to get diagnosed as TB cases. Using the data from the nationwide TB epidemiological survey, Wang et al. [6] reported that about 40% of the TB patients found in the survey had sought health care (mostly at the village and township levels), but had not been diagnosed as TB cases. The new policy developed by the national TB control programme in China requires the township health centres and village health stations to refer all TB suspects to their county TB dispensaries. Whether or not this new policy can help improve case detection rate needs to be evaluated in due course. Poor quality of TB treatment is another big problem, particularly in the areas where there were no effective TB control projects supported by the Chinese government and donors. It may be true that the TB cure rate among TB patients who have registered with the county TB dispensaries, particularly in the IECD project areas, has been as high as over 90%. However, the completion rate of TB treatment in the whole of China may
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not be as high as has been reported in many official reports. According to the nationwide TB epidemiological study, only one-quarter of 374 TB patients were receiving standardised treatment at the time the survey was conducted. The rest of TB patients either ceased the treatment before the course was complete or received intermittent treatments. Zhang [11] reported that TB patients in the poor areas usually could not complete the full course of their treatment due largely to their poor financial situation. Meng et al. [8] found that onethird of total TB-related medical care was incurred by patients before getting diagnosed as TB cases. In other words, a substantial amount of money was spent prior to achieving a TB diagnosis. Many TB patients were then not able to find any money to pay for appropriate treatments thereafter. There are many factors affecting failure to complete TB treatment. Some health professionals responsible for TB control reported that the side effects emanating from taking these drugs were one of the most important reasons why some TB patients stopped their treatments. However, the nationwide TB epidemiological survey showed that only 4.8% of TB patients ceased treatment or had intermittent treatment, owing to the side effects of the drugs. In addition, the directly observed treatment approach has been used in many parts of China. Usually, village health workers (rural doctors) are the persons responsible for observing the TB patients to take the drugs. Drugs may be sometimes kept at the village health stations and the TB patients are required to go to the village health stations to take the drugs once a day. As reported in Shandong Province where the IEDC project was implemented in 1992–1999, these village health workers were paid 30–40 Yuan (US$ 4–5) for each TB patients they cared for. It is said that DOT using village health workers as observers was not very successful in some places. The reasons include the following: (a) each village health worker on average only took care of up to three to four TB patients and they were not interested to earn such a small amount of money for a relatively long period; and (b) most TB patients, especially those living in remote or mountainous areas, were reluctant to visit the village health stations every day to take the drugs. Therefore, in most occasions, the village health workers, after several weeks of initial treatment, allowed the patients to take the drugs back to their home and asked one of patient’s family member as an observer. These patients usually visited
the village health stations once a month to take the bulk of the drugs back home. In the evaluation of IEDC projects there are several main problems related to the treatment of TB patients. First, the percentage of TB patients managed by TB dispensaries was very low. Those TB patients treated by general hospitals may have received different treatment regimes, some of which might not be effective. Second, controlling TB among the floating population has increasingly been difficult. There have so far been no practical measures for targeting rural migrants who fall ill with TB. Third, the capacity of TB service delivery, particularly in the poor rural areas, is not adequate, which has affected the effectiveness of TB control over the past decade. The final problem is that a majority of smear-negative TB patients have not been appropriately treated, even in the IEDC project areas, due largely to lack of resources. According to the estimates made by some Chinese leading TB experts, half of smear-negative patients may become smear-positive after a 5-year period, often due to irregular treatment, which may give rise to MDR. They then may infect other people in their communities. 4.3. Lack of co-operation and co-ordination between health facilities Lack of co-operation and co-ordination between health facilities in fighting TB is one of the greatest weaknesses in implementing TB control and prevention effectively in China. As discussed previously, the Chinese hospitals and other health facilities are stateowned and can therefore be called public hospitals or public health facilities. Nevertheless, they have been maximising profits through service provision and drug sales [13,14]. This is due partly to a relative decline of government funding given to support these preventive health facilities since the economic reform. Therefore, managers and directors of health facilities have now become more conscious of operational costs and profit making. According to the nationwide TB epidemiological survey conducted in 2002, over 80% of TB patients were diagnosed at general hospitals, rather than TB dispensaries. Doctors in these general hospitals who detected TB patients are obliged to report these cases to the county TB dispensary, according to the Infectious Disease Prevention and Treatment Law. In reality, however, only 15% of the TB patients diagnosed at
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general hospitals were registered with TB dispensaries [6]. In addition, in the IEDC project areas, smearpositive TB patients were entitled to enjoy free treatment and reimbursement of the expenditure related to TB diagnostic services. However, doctors at the general hospitals, due to their vested financial interest, tended not to tell the TB patients this information. Nor did they tend to refer them to the county TB dispensary. As a consequence of this, TB patients, and particularly the poor, ended up paying for all TB-related services out of pocket; a financial burden that should have been avoided. Such a problem in the implementation of health legislation and regulations is not uncommon in China since the introduction of the market economy. Tang [15] found that many health facilities, especially in the poor areas, have selectively implemented health legislations and regulations. When health facilities and health workers realised that certain health legislation can bring benefits to them, they have an incentive to implement it effectively and actively. When health legislation has negative implications for their financial interest, they tend to ignore it. The health sector reform undertaken in China has given the managers of health facilities more power and autonomy to do what they want to do, which has produced some negative impacts on TB control. Such a situation is also found in Kenya and in Zambia where the introduction of health sector reform may have brought about more difficulties and challenges to effective disease control programmes [16,17]. 4.4. Political and financial commitments of local governments Political and financial commitments of both central and local governments are vital to the effectiveness of TB control. In China, once the central government has made its political and financial commitments, it tends to honour them. However, this may not be the case with many local governments, especially at the county level of the poor areas. For example, in the IEDC project areas, local governments at provincial, prefecture/municipal and county levels, were required to provide a certain amount of so-called matching funds to co-finance the project. In fact, the project county governments only provided 56% of the committed funds during the project period. In Gansu province, one of the
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poorest provinces in China, the actual matching fund provided by the county government accounted for only 35.5% of the funds committed. As much research has shown, the fiscal status of county governments in the poor areas is often very poor. Once they have paid the salaries of their employees, little money is left for funding the social services for which they are supposed to take responsibility [18]. Failure to provide matching funds committed to the TB control project has jeopardised the implementation of the project. It is understood that some county governments in the poor areas were under pressure to commit themselves to allocate a certain amount of matching fund which they knew the county government would have formidable difficulties honouring. Such a failure to providing the matching funds has to some extent contributed to some county TB dispensaries’ over charging TB patients for diagnostic services and treatments. TB control projects in China only provided county TB dispensaries with necessary drugs and equipment. However, the costs of TB control operation at the county TB dispensaries, such as transportation, travel subsistence, maintenance and other consumable materials were supposed to be covered by a grant given by the county finance bureau. In the poor areas such a grant given to the TB dispensaries by the county governments has not been able to compensate for the rapid rise in operational costs, which is due largely to wage inflation, among other factors. The effective management of TB cases has come at a price. One district health manager responsible for TB control from Shandong province illustrated this point by stating that the more you have done for TB control projects, the heavier the financial burden your institution had to bear, since the county government health grant or the project budget given to the TB dispensary has usually been fixed at the beginning of the project. Meng et al. [8] found that the TB dispensaries in Shandong, like their counterparts in other provinces, tried to provide other services (e.g. treatment of STDs) that can generate revenues for their institutions. Zhan et al. [9] also found out that some TB dispensaries asked TB patients to take unnecessary X-ray examinations every month in order to generate revenues. Both inadequate government funding for TB control and perverse incentives to the health staff (i.e. getting more bonuses through generating revenue) are responsible for such behaviours.
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The above analysis of possible causes of the main problems related to effective TB control and prevention in China over the past decade also illustrates to some extent the limitations and constraints of implementing the DOTS strategy in many parts of China. Several DOTS elements, such as supply of TB drugs and central government commitment, have been successfully implemented in China, while other DOTS elements have not yet been effectively implemented in some parts of China, and particularly in the poor areas. The analysis and discussion presented above also reveals that most of the main problems associated with ineffectiveness of TB control can be attributed to weaknesses in the Chinese health care system.
5. Opportunities and challenges for next decade TB control and prevention has in recent years been a top priority for the Chinese government with the support of many international organisations. After the completion of the IEDC project, the World Bank, working with the Department for International Development, UK, has helped the Chinese government to develop a new large TB control project with over US$ 200 million, covering 16 provinces (most of which are poor provinces) and almost half of the Chinese population. In 2002, the Global Fund against HIV/AIDS, TB and Malaria offered a large grant of US$ 48 million for TB control in China. CIDA, Canada has also recently approved over one million dollars for TB control in three provinces of China (Shandong, Jiangsu and Zhejiang). JICA and Damian Foundation, Belgium, as well as WHO WPRO, have also been supporting TB control and prevention in China. Besides all this international support, the central Chinese government and an increasing number of local governments in China have committed extra funds for fighting TB in the recent years. All this political and financial support is an excellent opportunity for China to build upon what it has done in TB control and continue to tackle the TB epidemic and poverty in a more effective way. In addition, the IEDC project and the MoH supported TB control projects, as described above, have provided many lessons and experiences for future TB control in China. The continuation of good practices should be promoted, while attention should be paid to
the lessons learnt from the previous projects in developing new projects. Furthermore, good practices and lessons from other developing countries have also been available to China via the technical support from the WHO as well as international collaboration through a variety of international organisations. While China has a historical opportunity to fight TB, there are also many challenges facing such a tough war against this great public health and social problem. Low case detection rate (case finding) is the most important challenge facing the effectiveness of TB control and prevention in China, as pointed out by Chen et al. [4]. Whether or not China can develop a series of robust measures to increase the case finding is a key to the success of TB control in the near future. It is essential and imperative for the Chinese central and local governments as well as international communities to pool financial resources for fighting TB in China. But, while financial resources are necessary, they are not sufficient in ensuring that all these TB control projects mentioned above will be effectively implemented. Human and physical/infrastructure capacities are also very vital to the success of implementing these projects in the next decade. Challenges for the poorer areas of China are how to get good project managers and TB experts to deliver the expected outputs and outcomes that the Chinese governments and international communities want to see with the huge amount of financial resources committed. The development of rational mechanisms of financing all the health facilities responsible for TB control and prevention is also very important. Tackling financing mechanisms is central to ensuring that general hospitals, particularly at the county level, are willing to co-operate with county TB dispensaries in the operation of referring, reporting, case management, and monitoring. Without good co-operation between these health facilities, the effective implementation of these TB control projects in China may be in a great jeopardy. The remuneration of health staff responsible for TB treatment and prevention in all types of facilities needs to be properly addressed and dealt with. Public health workers’ income should not be linked to the quantity of the revenue they generate through charging patients for TBrelated services they provide. All this needs a reform of the current Chinese health care system so that TB control can develop in a healthy and sustainable fashion.
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6. Suggestions and recommendations This section offers some recommendations on developing more robust TB control measures and on the areas for further research towards effective TB control in China. Each recommendation is presented in order of priority. The expansion of DOTS implementation to the whole country should be put as a top priority in the years to come, since the benefits of successful DOTS implementation in many parts of China have been demonstrated over the past decade. Particular efforts should be made to improve and strengthen the implementation of some DOTS elements that have blocked the speedy reduction of TB prevalence rates in some areas of China. Policy-makers and health professionals should be aware that the expansion of DOTS implementation may not automatically result in national TB control programme reaching the poor, a key element for an increase in case detection rate. It is also very important to mobilise political support from local governments, particularly in the poor areas. Local politicians and government bureaucrats should be made aware of TB being not only a serious public health problem, but also a social problem. They should also pay special attention to TB control in their areas. One important action that the national TB control programme should take in the near future is to develop proactive approaches to TB case finding. One approach could be the establishment of a community-based TB surveillance system, using trained village health workers. Village health workers in the areas of high TB prevalence rates could be trained to identity TB suspects proactively and refer them to the county TB dispensary, probably via township health centres, for chest X-ray fluoroscopy and sputum tests. Monthly regular meetings with these village health workers could be organised at the township health centres to discuss TB-related matters, among others. They should be financially adequately awarded, regardless of whether or not the TB suspects they refer are found smear positive, provided that their performance has been appropriate. Action research (via pilot studies) needs to be considered to test new strategies and approaches that can be more effective in improving case finding in the poor areas where the TB notification rates have been low. These strategies and approaches should be based on the assessment of po-
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litical, financial, cultural and administrative feasibility. Information, Education and Communication (IEC) in relation to TB care should be widely available to the public. By developing an appropriate IEC strategy and implementing it effectively, the national TB control projects should aim to achieve several specific objectives. The first is to increase the awareness of the TB epidemic among the public and the leadership at different levels of local government. The public needs to be provided information and education on TB and its implication for the health of individuals, households and communities, as well as financial burden associated with untreated TB. The fact that TB is treatable should be a central part of these campaigns in order to tackle stigma. Secondly, the public needs to know government policies on fighting TB, e.g. smear-positive TB patients can get free diagnosis and treatment, via newspapers and TB adverts, etc. To achieve this, the TB control projects being implemented should allocate adequate budgets to publicise the policies of this kind by a variety of means. In addition, to develop effective means of publicising the message that TB is curable in order to reduce stigma would have to be an important part of such work to avoid imposing negative social consequences on those identified as TB cases. Research should be done to identify which means is most effective in communicating with the public. Appropriate financial mechanisms should be developed to ensure that TB control projects, especially in the poor areas are well resourced. It is inappropriate for the TB control projects to require county governments, and even prefecture governments, in poor areas to provide matching funds to support the TB control projects being implemented in their areas. Moreover, the poor who suffer from TB should not only be provided free diagnosis and treatment, but also given some financial support to cover indirect costs associated with TB treatment through medical financial assistance schemes. TB case management in China, as a whole, has not been functioning well, because of lack of co-operation between general hospitals and TB dispensaries. The proportion of TB patients who register with TB dispensaries has been extremely low, since physicians at the general hospitals have disincentives to refer their TB patients to the TB dispensaries. They do not even tend to report TB cases as required by the Infectious Disease Prevention and Treatment Law. Adequate in-
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centives could be investigated and developed to ensure that the regulations are effectively implemented. In the meantime, vigorous administrative intervention for better co-operation in TB case management between health facilities should be imposed across the country. Appropriate means for discipline, if necessary, should be taken against those doctors and hospitals violating the law. As a whole, it is vitally important to explore appropriate approaches to engaging hospitals and other health facilities in the implementation of DOTS. In the short term, TB control in China faces formidable barriers to success without a wider health system engagement in the implementation of DOTS expansion, and a focus on quality service delivery for the poor.
Acknowledgements The authors of the paper would like to express their sincere appreciation to many people, particularly Zhao Fengzeng, Wang Lixia, Wang Xuejing, Zhou Jiqian, Gong Youlong, Meng Qingyue, Li Renzhong, Zhang Tuohong, Zhan Shaokang, Jiang Xiwen and Daniel Chin who have generously spent their valuable time to discuss issues and problems related to TB control in China, and shared their TB-related research materials and experiences with us. Comments from Rachel Tolhurst, Wang Xuejing and others are highly valued and appreciated. The EQUI-TB Knowledge Programme based at the Liverpool School of Tropical Medicine and funded by DFID has been supporting the research on TB control in China.
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