Original article An Epidemiological Study of Tuberculosis Patient with Special Reference to Cost Incurred By Patient for the Treatment in an Urban Slum of Mumbai, Maharashtra Dnyaneshwar M. Gajbhare 1, Rahul C. Bedre 2, Harsha M. Solanki 3 1Assistant Professor, Dept. of Community Medicine (PSM), T. N. Medical College & BYL Nair Hospital, Mumbai, Maharashtra, India 2Assistant Professor, Dept. of Community Medicine (PSM), Bidar Institute of Medical Sciences, Bidar, Karnataka, India 3Assistant Professor, Dept. of Community Medicine (PSM), Government Medical College, Bhavnagar, Gujarat, India Corresponding author: Dr. Dnyaneshwar M. Gajbhare Abstract: Context: Tuberculosis remains a major public health problem in the world. It infect one third of world population at any given point of time. Objectives: To study total cost incurred by TB patients for treatment in an urban slum area Mumbai, Maharashtra. Methodology: A community based longitudinal study was carried out for 12 months in field practice area of UHC facilitated by Community Medicine Department of KEM Hospital, Mumbai, Maharashtra. All patients registered during study period (103) were included of which 85 were able to follow till completion of study. Initial interview focused on socio-demographic profile of patient, pre-diagnosis history of illness & cost incurred for the same followed by monthly visit to patient s home to get information regarding monthly expenses during treatment. Based on information pre-treatment (direct & indirect) cost as well as during treatment (direct & indirect) cost incurred by patient for treatment was estimated. Results: Category wise distribution of TB patients was 46.6%, 22.3% & 31.1% for cat 1, cat 2 & cat 3 respectively. Past h/o TB was present in 24.3% & family h/o TB was present in 40.2% patient. The mean pretreatment working day s loss & during treatment working day s loss was more for category 2. Pre-treatment mean direct cost was Rs.518.79 & it was more for category 3 patients. Pre-treatment mean indirect cost for employed patients was Rs.1698.40 & it was more for category 2 patients. During treatment cost was estimated for patients who had completed treatment successfully. Mean direct cost & indirect cost during treatment was Rs.1149.31 & Rs.4677.40 respectively. It was more for category 2 patients. Mean total cost {pre-treatment (direct + indirect) + during treatment (direct + indirect)} of tuberculosis treatment for an employed patients who had completed treatment successfully was Rs.8465.63.it was more for category 2 patients. Total cost was 14.53% and indirect cost was 11.31% of total family income of employed patients. Conclusion: The cost incurred to the patient was much more in proportion to their annual income and it was more for category 2. Key words: Socio-demographic profile, cost incurred for TB treatment, urban slum 50
Introduction: Tuberculosis is one of the most ancient diseases. It is an airborne infectious disease that is preventable and curable. The causative agent was detected more than 100 yrs back by Dr. Robert Koch on 24 th march 1882. In spite of complete knowledge about causation, spread and treatment of disease, it is not possible to have control over the spread of disease. Tuberculosis remains a major public health problem in the world. It infect one third of world population at any given point of time. The developed country was able to control the disease to certain extent but due to HIV infection the disease started appearing again. Tuberculosis is one of the disease which causes heavy economical loss to mankind. World Bank has estimated global burden of tuberculosis in terms of DALYs loss and stated that Tuberculosis stands 7 th globally in DALYs loss. The families of tuberculosis patient suffer a heavy socio-economical loss (1). India has the highest burden of tuberculosis (TB) globally, accounting for one fifth of the global incidence and two thirds of the cases in South-East Asia. Nearly 40% of the Indian population is already infected with the TB bacillus. India has more new TB cases annually than any other country, ranking first among the 22 high-burden TB countries worldwide according to the World Health Organization (WHO) Global TB Report 2006. India began a Revised National Tuberculosis Control Program (RNTCP) with Directly Observed Therapy, Short-Course (DOTS) implementation in 1997. According to WHO, DOTS was available to 84 percent of the population in 2004 and in March 2006 complete India was covered under DOTS. Need for study: Tuberculosis (TB) affects the most productive age group and the resultant economic cost for society is high. Even though diagnostic and treatment services under TB control are offered free of cost, TB patients do incur out of pocket expenditure. There are several studies on effect of RNTCP on the treatment outcome of patient. The issue of economical impact remains unattained in most of the studies. Hence the present study was a small attempt to study the economical impact of tuberculosis in study population. Materials and Methodology: Present Community based longitudinal study was carried out for 12 months in field practice area (Malvani Urban slum area) of UHC facilitated by community medicine department of KEM Hospital, Mumbai, Maharashtra. Malvani is divided into Gates and areas of which Gates extend from Gate No1 to Gate No 8. The UHC is located at Gate No.7 Malvani which is served by two health posts. The area under the health post which is attached to UHC was taken for study. All the patients registered during study period (from 1 ts September 2005 till 31 th December 2005) to health post i.e. 103 were included of which 85 were able to be followed till completion of study. First interview was conducted immediately after starting treatment under DOTS which mainly focused on the sociodemographic profile of patient, pre-diagnosis history of illness and cost incurred for the same. After initial first interview the patients were followed on monthly basis to their home, when ever required the information given by patient was cross checked by seeing the details during visit to the home of patient. The subsequent visits session were used for collection of information regarding monthly expenses during treatment. The various type of cost estimation of entire treatment was done at various levels. The pretreatment direct cost was estimated for all patients (n=103). The pretreatment indirect cost was estimated for only employed patient (n=52). During treatment the direct cost was estimated for all those patients who completed treatment successfully 51 50
(n=85). The indirect cost during treatment was estimated for those patients who completed treatment successfully and were employed (n=41). As estimation of indirect cost in unemployed patient was not possible as the time lost on account of non-labour activities cannot be measured in financial terms, thus indirect cost was estimated only in employed patient. Thus analyses of patient who completed treatment and employed were taken for analysis. Data analysis: Data entry and analysis was done using SPSS software version 15. This was cross checked by manual calculation. Framework: Total patient registered (n=103) Total patient interviewed (n=103) for all patient (n=103) Pre treatment cost assessed Direct cost for all patient (n=103) Indirect cost for employed (n=52) During treatment cost for patient who completed treatment (n=85) Total cost (direct and indirect) for Patient who completed treatment and employed. (n=41) Direct cost for patients who completed treatment (n=85) Indirect cost only for employed patients who completed treatment (n=41) Operational definitions used in the study: Costs assessed 1. Direct medical costs: Consultation fees and money spent on investigations and drugs were classified as medical expenditure (2). 2. Direct nonmedical cost: Money spent on travel, lodging, special food and expenditure incurred for persons accompanying the patient were classified as nonmedical expenditure (2). 3. Indirect costs: Indirect costs were classified as loss of wages due to illness, decreased earning ability due to illness, or long term disability that necessitated change in type of work (2). 5251
4. Total cost: Total cost includes the expenditure incurred pre treatment and during treatment under direct and indirect costs (2). Results and Discussion: Table 1: Socio-demographic Profile of the TB patients Variables No. % Age (years) 00-14 10 09.70 15 24 36 35.00 25 34 24 23.30 35 44 16 15.50 45 54 08 07.80 More than 54 09 08.70 Sex Male 57 55.33 Female 46 44.67 Education Illiterate 26 25.24 Primary 23 22.34 Secondary 28 27.18 Higher secondary 10 09.71 Above tenth 16 15.53 Occupation Unemployed 51 49.51 Employed 52 50.49 Socio-economic class Upper Class 00 00 Upper-Middle Class 20 19.4 Middle Class 48 46.6 Lower Middle Class 28 27.2 Mean age of cases was 28.95yrs; similar study conducted by R. Rajeswari (3) showed that the mean age was 37.8±14.9 yrs. Another study by Dheeraj Gupta (4) shows that the mean age in study population was 35.56±13.69 yrs. Study from Zambia by D. M. Needham (5) show the mean age of study subject was 32 years. In present study the mean age is slightly lower than the previous studies it may show the increasing incidence of disease in younger population. Tuberculosis affects all age group, but has its greatest impact on productive adults. It is well known that adults aged 15 to 59 years are the most economically productive individuals; as they are parents on whom survival and development of children depend. In present study, maximum number of patients (35.00%) was 5351
in age group of 15-24 yrs followed by 25-34 yrs (23.30%). Thus Tuberculosis affects highly productive age group individuals i.e. 15-34 years & here it contributes 58.30%.Similar study conducted by R. Rajeswari (3) showed that 69% male and 84% female were in the economically productive age group 15 to 49 yrs. The occurrence of tuberculosis does not depend on the sex of individual. In present study the distribution of study population shows that the male were 55.33% and the female were 44.67%. The male were affected more than the female population, these may be due to unhygienic living standard, inadequate diet, heavy physical work, various types of addiction. A study conducted by R. Rajeswari (3) showed that the male were affected to an extent of 56.95%. Similarly another study by Dheeraj Gupta (4) titled as Role of socioeconomic factors in tuberculosis prevalence shows that the male were 67.2% affected while the females are affected in 32.8% cases. There is another similar finding in a study conducted by M. Muniyandi (2) shows that there were 73% male contribute to the study population. A large number of study populations were uneducated 26 (25.24%). As level of education is an important factor in association with knowledge about disease and the various services available at government centers. Educational status of the community is very key factor for the success or failure of the treatment in tuberculosis. Health seeking behavior of individual depends on the educational level; in present study only 17 out of 26 (65.04%) go to health provider in first 30 days of their sickness. In study population individuals educated till primary classes were 22.34% while only 15.53% were educated above tenth standard. A study named cost to patient with tuberculosis treated under DOTS programme conducted by M. Muniyandi (2) showed that 43.29% study population was illiterate. A similar study conducted by R. Rajeswari (3) in India showed that 25% male and 34% female were illiterate. In present study there were 49.51% unemployed individuals (Students, Retired person and Housewives) while there were 52 (50.49%) employed individuals in study population (Government employee, Private employee and daily workers). Employment status affects the treatment outcome as well as treatment adherence. It is important in estimation of indirect cost of the tuberculosis that the diseased individuals need to pay. Higher the employed higher will be the indirect cost. Unemployment status was 21.31% in a study named cost to patient with tuberculosis treated under DOTS programme conducted by M. Muniyandi (2). In another study by R. Rajeshwari (3) the employment status of 52.30% study individuals was employed. It is clearly that there were no cases from upper class in present study. This shows that Tuberculosis affects middle class and lower class. In present study it affects middle class in 46.6% of cases while lower middle class and lower class were affected in 34%. There are various factors in support of involvement of middle and lower class by the tuberculosis. These may be Unemployment, lower Educational Level, unhealthy living environment and Overcrowding etc. There is a study titled as cost to patient with tuberculosis treated under DOTS programme conducted by M. Muniyandi (2) shows that the 61.75% cases belong to Below Poverty Line (BPL). Graph 1: Categorization of patient as per Disease category. 54 54 51 54
Majority of patient 48 (46.6%) belongs to Category 1 followed by category 3 (31.1%) while Category 2 Graph : 1 contributes to 23 (22.3%). 46.6 DISEASE CATEGORY-WISE PATIENT PROFILE Percentage (%) 50 40 30 20 10 22.3 31.1 0 Category 1 Category 2 Category 3 Disease Category Table 2: Category wise pre-treatment and during treatment loss of working days Disease category Pre-treatment mean days loss During treatment mean days loss Category 1 10.92 29.35 Category 2 13.87 34.22 Category 3 4.06 23.56 The mean pre-treatment & during treatment working day s loss was more for category 2. Similar finding was observed in a study conducted by R. Rajeshwari (3) there was 60 days loss of working days for complete treatment. In present study it was 44 days for category 2 patient. In a study in study by Needham D M (5) in Zambia shows that mean pre-treatment days lost were 12.5 to 20 days. Medworld asia Dedicated for quality research www.medworldasia.com Table 3: Mean pre-treatment cost (direct+ Indirect) & during treatment cost (direct + Indirect) of Patients (Cost in Rupees). 55 51
Table : 3 Cost incurred Sample size Mean Minimum Maximum Pretreatment Direct Treatment 103 518.79 10.00 8700.00 Indirect Cost 52 1698.4 00.00 9000.00 During treatment Direct Treatment 85 1149.31.00 4160.00 Indirect Cost 41 4677.40.00 24000.00 The above table depicts that mean pretreatment as well as during treatment indirect cost was more compared to direct cost. Indirect costs includes as loss of wages due to illness, decreased earning ability due to illness, or long term disability that necessitated change in type of work. The direct medical cost had a wide range from minimum Rs.10 to maximum Rs.8700, this variation depend on the various factors as sex of individual, age, type of health care provider and category of disease. Mean pre-treatment indirect cost was Rs.1698 with a minimum of nil to maximum of Rs. 9000 in present series of patient. The pre-treatment indirect cost shows the awareness of health in the study population. Higher the pre-treatment cost higher will be loss of working days. In present study mean pre-treatment working days lost was 9.44 with minimum zero and maximum 90 days. In a study by Dinesh M Nair (6) in Mumbai shows that a total of US $ 10 was spent for consultation and drugs before diagnosis by a patient residing in Mumbai. Similarly in a report by Uplekar M (7) in 1996, patient registered for treatment with government-run services incurred a pre-treatment cost of US $ 10-17; this is considerably higher than pre-treatment costs for the patient in the present series. In a study by M. Muniyandi (2) the pre treatment direct cost was Rs.874 which is much higher than the present study & pre-treatment indirect cost was Rs.951. The difference may be just due to the period of study, the study was conducted in 2000.. Similarly in a study by R. Rajeswari (3) the mean direct cost was Rs.2052 & pre-treatment indirect cost was Rs.3818. During treatment direct cost was estimated for those who completed treatment. Out of total 103 patient 85 completed treatment and the mean direct cost treatment was Rs.1149.31. During treatment indirect cost was estimated for employed patient who completed treatment successfully. In present study there were 41 patients who completed treatment successfully and they are employed. During treatment indirect cost was Rs.4677.40 with a range of Rs.00 to Rs.24000. Similarly in a study by M. Muniyandi (2) mean direct cost during treatment was Rs.227 & mean indirect cost was Rs.825 with a range of Rs.0 to Rs.13100which is much lower than the present series of patient. In a study by R. Rajeswari (3) the mean direct cost during treatment was Rs.219 for the entire course of treatment & the mean during treatment indirect cost was Rs.3863. The difference in the present study series and available studies may be due increasing price of daily commodity. 56 51
Table 4: Mean Pre treatment cost (direct + indirect) & during treatment cost (direct + indirect)) of employed patient according to Disease category (Cost in Rupees). Cost incurred pretreatment & during treatment Disease Category Mean Minimum Maximum Pre-treatment direct cost (103) Cat 1 435.00 10.00 6300.00 Cat 2 272.17 10.00 990.00 Cat 3 821.72 90.00 8700.00 Pre-treatment indirect cost (52) Cat 1 1995.33 00.00 9000.00 Cat 2 2260.71 00.00 8000.00 Cat 3 521.79 00.00 2000.00 Direct cost during treatment (85) Cat 1 1072.59.00 4160.00 Cat 2 1978.82 400.00 3540.00 Cat 3 743.52.00 1920.00 Indirect cost during treatment (41) Cat 1 4919.17 1000.00 18000.00 Cat 2 7311.67.00 24000.00 Cat 3 1843.03.00 4666.67 The study shows that there is significant difference defaulter, relapse or failure individuals. These in pre-treatment cost of patient as per disease patients have already diseased condition. During category. There is maximum pre-treatment indirect treatment direct & indirect cost was maximum for cost in disease category 3 followed by category 1 category 2 patient which may be due to due to long and category 2. This difference may be due to the duration of treatment course and patient need investigation required in diagnosis of disease. maximum care. Further it may leads to loss of Category 3 needs investigation like fine needle working days of a patient as well as hampers the aspiration cytology (FNAC), biopsy for cytology socio-economic development of individual and etc this are expensive investigation. Pre-treatment society. indirect cost was maximum for category 2, as this category includes either previously diseased, Table 5: Mean Total cost for Employed patient. (Cost in Rupees) 57 51 57
Table : 5 International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 02, January 2015, Pages 50-59 Sample size Mean Minimum Maximum Total cost 41 8353.63 1710.00 35510.00 Disease category Category 1 8608.13 2510.00 31880.00 Category 2 12501.67 2556.67 35510.00 Category 3 4120.15 1710.00 10480.00 In present study the total cost (Pre-treatment direct, indirect and during treatment direct, indirect) was estimated for patient who were employed and completed treatment successfully. The mean total cost for treatment of tuberculosis in present study was Rs.8353.63 with a range of Rs.1710 to Rs.35, 510. Mean total cost was found more for category 2 as compared to other categories. In a study conducted by M. Muniyandi (2) the mean total cost was Rs.1398 (US $ 30), total cost was more than Rs.3000 in more than 29% patient. In another study by R. Rajeswari (3) tuberculosis treatment was Rs.5986. the mean total cost for Table 6: Proportion of Indirect and Total cost of employed patient to that of annual income Total employed patient Mean annual family income (Rs) Indirect cost (Rs) Total cost (Rs) 41 57,453.56 6502.19 8353.58 It is observed that total cost was 14.53% and of the below poverty line patient and 10% of the indirect cost was 11.31% of total family income of above poverty line patients annual family income. employed patients. In a study conducted by M.Muniyandi (2) shows that the total cost was 19% Graph 2: Proportion of Indirect and Total cost of employed patient to that of annual income. 14.53% Total cost Total income Conclusions: 58 58 51
Conclusion: Tuberculosis affects mainly the productive age government health centre, there is no estimate of group of society thus it hampers the social and cost those taking treatment from private centers. economical development of individual, society and Recommendations: the nation. It is mostly seen in the middle and It is strongly recommended that all effort below middle class community which are already should be made to ensure that correct, struggling for their survival in day to day life. regular and complete treatment is taken by Disease category 2 causes maximum working days the patient. loss both in pre-treatment as well as during There is need to provide adequate financial treatment. The cost incurred to the patient is much support to tuberculosis patient from the more in proportion to their annual income. poorer section of the community, since Limitations: they are thrown even further into poverty In spite all efforts made to collect the accurate as a result of the disease. information regarding expenditure of patient, there There is need for starting income may be some overestimation of cost. The study generation scheme for the adult patient as population was only those taking treatment from they are the earner of the families so as to meet their daily family needs. References: 1. J Kishore s National Health Programs of India, 7th Edition. pg-168. 2. M. Muniyadi, Rajeswari Ramachandran and Balasubramanian. Study on cost to patient with tuberculosis treated under DOTS programme. Indian J Tuberc 2005;188-196. 3. Rajeshwari R, R Balasubramanian, Muniyandi M, Geetharamani, X. Thresa, P. Venkatesh. Socioeconomic impact of tuberculosis on patients and family in India. Ind J Tuberc Lung Dis 1999; 3(10): 869-77. 4. Dheeraj Gupta, Kshaunish Das, Balamughesh, T., Aggarwal, A. N., Jindal, K. Role of socio-economic factors in tuberculosis prevalence. Indian J Tuberc 2004; 51:27-31. 5. D.M. Needham; P. Godfrey-Faussett; S.D. Foster. Barriers to tuberculosis control in urban Zambia: the economic impact and burden on patients prior to diagnosis. Ind J Tuberc dis 2(10); 811-17. 6. Nair, D.M., George, A., Chacko, K.T. (1997), "Tuberculosis in Bombay: new insights from poor urban patients", Health Policy and Planning 1997;12(1):77-85. 7. Uplekar M, Juvekar S, Morankar S: Tiberculosis patient and practioners in private clinics. Bombay: The Foundation for Research in Community Health, 1996. 59 51