More than half of tuberculosis (TB) patients in Chinese hospitals are treated incorrectly, and the overuse of second-line TB drugs poses a serious problem according to a large implementation research project led by the Global Health Research Center of Duke Kunshan University, in collaboration with China Centers for Disease Control and Prevention (China CDC), and a couple of Chinese universities, with support from the Bill & Melinda Gates Foundation.
The collaborative research project, which examined TB care and medication use in China from 2009-2015, found that TB care in Chinese hospitals is uneven, with both an over-use and under-use of treatments. The inconsistent treatment results from a combination of inappropriate economic incentives, lack of knowledge about infectious disease control and misguided health insurance policies.
Those findings and others were published recently as a thematic series in ten papers by the journal Infectious Diseases of Poverty. Some of the researchers’ recommendations are already being implemented at the project sites.
While the prevalence of TB in China declined significantly between 1990 and 2010, as of 2013, the country still has the second highest burden of TB and multi drug-resistant TB (MDR-TB) in the world.
Basic TB care in China is free of charge, but the researchers found that the more complex drug-resistant disease adds a significant layer of expenses, with additional charges related to medications, such as liver protection drugs, unnecessary diagnostic tests, and patient transportation that add financial burden to patients, especially the poor.
The researchers found that:
- Over-using TB services often results in substantial medical and non-medical expenditures for completing TB treatment.
- More than half of the Chinese TB patients in the study had significant health expenditures that caused financial problems.
- One fifth reported similarly devastating spending on non-medical expenditures.
- Poor patients were less inclined to seek TB care because of the financial burdens.
- Enrollees in the New Cooperative Medical Scheme (NCMS) had the lowest rate of reimbursement, which meant that poor patients receiving coverage by NCMS were more susceptible to financial hardship from TB treatment costs.
About the project
Phase One: 2009-2012
The first phase of what has come to be known as the ‘China-Gates project’ focused on diagnosis, treatment and financing of care related to MDR-TB. TB care has been shifted from the China CDC to local general hospitals. A number of county-level hospitals were designated as TB hospitals. Funding for TB clinical care is now mainly taken on by health insurance in China, rather than earmarked funding from the government.
Phase Two: 2012-2015
Multiple parties representing health insurance management agencies, government agencies responsible for poverty reduction, municipal governments and international health care finance experts developed two major reforms for the financing of TB care that were put in place at the three research program sites in 2014.
Researchers and collaborators developed and implemented new financing models for TB and MDR-TB care and control in three cities across China: Zhengjiang City, Jiangsu Province, in the eastern region; Yichang City, Hubei Provence, in the central region; and Hanzhong City, Shaanxi Province, in the western region.
Multiple parties representing health insurance management agencies, government agencies responsible for poverty reduction, municipal governments and international health care finance experts developed two major reforms for the financing of TB care that were put in place at the three research program sites in 2014. First, all of the health insurance providers agreed to increase reimbursements to hospitals for the more complex MDR-TB-related inpatient and outpatient care. Second, hospitals were reimbursed, using case-based payment method, instead of fee-for-service, to contain costs.
Researchers then began a deep examination of TB/MDR-TB care and financing in the three cities. They used surveys to:
- understand the current state of TB/MDR-TB care, financing and provider payment mechanisms,
- generate baseline data in order to evaluate the new financing models and payment methods as they relate to the equity and efficiency of TB care, and
- examine the provision and quality of TB care and control.
The researchers also surveyed patients, providers and other stakeholders to fully understand the scope of the problem and begin proposing solutions.
The research team has submitted its final report which will be disseminated at a national workshop scheduled in March 2016. The Chinese CDC has already made policy changes in its TB diagnosis and treatment guidelines. And the government has initiated financial interventions. These will include additional reimbursements to hospitals and subsidies to patients for TB care, and new incentives to hospitals to encourage a rational use of drugs.
The Gates Foundation will support the scale-up of successful policy interventions for three years beginning in 2016. Duke University is asked to lead the monitoring and evaluation of that effort.