Kings Of Convenience Versus

[Billie Kjergaard]

InViet Nam, tuberculosis (TB) represents a devastating life-event with an exorbitant price tag, partly due to lost income from daily directly observed therapy in public sector care. Thus, persons with TB may seek care in the private sector for its flexibility, convenience, and privacy. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector.

Between October 2020 and March 2022, we conducted 110 longitudinal patient cost interviews, among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program (NTP) in Ha Noi, Hai Phong and Ho Chi Minh City, Viet Nam. Using a local adaptation of the WHO TB patient cost survey tool, participants were interviewed during the intensive phase, continuation phase and post-treatment. We compared income levels, direct and indirect treatment costs, catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression.

Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector. Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector, use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.

In Viet Nam, an estimated 172,000 individuals fell ill with TB, including 9200 people with drug-resistant TB in 2022, causing an estimated 13,600 deaths [14]. Quality-assured TB care is provided by the National TB Program (NTP) at District TB Units. While persons with TB receive diagnosis and treatment largely free of charge, pre-treatment services such as chest x-ray and liver function tests have to be paid out of pocket. A nationally representative patient cost survey of persons with TB receiving treatment from the NTP found that 63% of households affected by drug-susceptible TB (DS-TB) experienced catastrophic costs. The catastrophic cost incurrence was primarily driven by lost income associated with the inability to retain employment or paid leave, or having to switch to less laborious occupations with lower levels of remuneration. Root causes of these productivity losses were the TB-related disabilities and directly observed therapy (DOT) requirements tied to the quality-assured TB care provided by the NTP [15].

In response, 31% of persons with TB in Viet Nam seek care in the private sector. Despite concerns about the quality or safety of care, and potential supply-induced demand [16,17,18], the greater privacy to protect from stigma and related negative social consequences especially for women [19,20,21,22] along with the convenience of self-administered treatment, multi-day dosing, shorter wait times and after-hour consultations are perceived to outweigh high out-of-pocket treatment costs [23,24,25,26]. However, to date there have been no studies to verify this perceived trade-off by directly comparing catastrophic cost incurrence in TB-affected households between people receiving care from the private sector versus the NTP. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector.

This was a prospective cohort study to measure the comparative patient costs and rates of catastrophic cost incurrence among affected families due to an episode of DS-TB in public and private sectors. Data were collected using a localized, longitudinal adaptation of the WHO patient cost survey tool.

The study was conducted in Ha Noi, Hai Phong and Ho Chi Minh City (HCMC). These high TB burden, urban provinces had a combined population of 19.1 million persons per the latest census and according to NTP surveillance notified 23,502 persons with DS-TB in 2019. Since 2017, the Viet Nam NTP has implemented a private sector engagement model with an implementation partner, Friends for International TB Relief, serving the role of an intermediary agency to collect, verify and notify private TB treatment data [16]. This collaboration enabled the patient cost comparisons between private and public cohorts.

The study population consisted of persons with DS-TB taking and completing treatment with the NTP or a private healthcare provider. Recruitment occurred between October 2020 and March 2022 and employed a continuous sampling strategy for the private cohort. Participants for the public cohort were recruited to match with private participants in terms of residing district and treatment initiation date. All treatment-nave persons aged 18 years or older with pulmonary DS-TB, residence in the study provinces and providing informed consent to participate were included. Persons already participating in or with a household member participating in another patient cost survey were excluded to avoid double counting this household in the overall dataset, and avoid bias from overstating the risk of catastrophic costs.

Household incomes pre-treatment, during the intensive phase, the continuation phase and at the end of treatment for both cohorts were tabulated by mean and standard deviation, as well as median and interquartile range, and compared by Wilcoxon rank-sum test due to their right skewed distribution.

Patient cost calculations followed WHO guidelines [9]. Direct medical costs encompassed consultations, diagnostic tests, hospitalizations and medications. Direct non-medical expenses encompassed expenditure related to food, travel and accommodation arising from medical visits, supplements and loan interest. Indirect costs were defined as reported income loss during treatment only and were calculated using the output approach with caregiver time loss excluded to match the national patient cost survey [15]. We calculated mean and median direct medical, direct non-medical and indirect costs for the entire episode of TB, as well as disaggregated into pre-treatment and treatment phases. Given large standard deviations, we used the Wilcoxon rank-sum test to analyze differences in costs between the two cohorts. We disaggregated total treatment costs by main cost components (medical, non-medical and indirect) and direct medical costs by unplanned health care visits and hospitalizations, drug pick-ups, and follow-up appointments. These cost breakdowns were compared across cohort using t-tests for proportions.

Catastrophic cost was defined as total costs exceeding 20% of the annual household income prior to diagnosis [9]. The catastrophic cost estimates for the two cohorts were compared using χ2 tests. We fitted univariate and multivariate logistic regression models to assess the association between catastrophic cost incurrence as the primary outcome and survey cohort as the primary exposure. Secondary covariates were included to adjust for confounding included demographic, socioeconomic, behavioral and health-seeking factors based on prior research [29,30,31]. A post-hoc analysis to investigate the association of household income and patient costs in the private sector did not yield relevant associations (Additional file 1).

Our study found no difference in catastrophic cost incurrence in public and private sector TB treatment. Surprisingly, we also did not detect a difference in indirect costs, which disproves our hypothesis that the lack of DOT in private sector care can alleviate costs from lost salaries and wages. Conversely, as expected we measured high direct medical costs before and during treatment in the private sector, largely arising from drug pick-ups, as well as higher pre-treatment household incomes among private sector participants to help absorb the higher treatment costs. Overall, our study highlighted that an episode of TB in Viet Nam represents a costly life-event, irrespective of whether treatment is sought in public or private sectors, with catastrophic costs mainly driven by economic and social factors.

Another risk factor of catastrophic cost incurrence was patient-experienced stigma. Studies have reported that public sector care and the associated DOT requirement may intensify stigma [41, 42]. Consequently, there is a growing momentum towards people-centered care that addresses social determinants, including stigmatization [43]. As part of this movement, demands have included the phase out of traditional DOT, which has constituted a pillar of public sector patient management over the last three decades [44,45,46]. Removing the DOT requirement could both reduce stigma and alleviate much of the indirect cost burden in the public sector, which represented 52% of total treatment costs within the NTP cohort and was equal to the average monthly household income before the episode of TB.

While the lack of DOT has long represented a core value proposition of the private sector to clients [19, 47], it also constitutes one of its core criticisms from a public health perspective, due to suspicions of fueling drug resistance [17, 48]. Thus, it may be helpful to offer an alternative to ensure that the quality of care is maintained. Many process alternatives to facility-based DOT have been deemed effective for patient care [46, 49]. Specifically, these alternatives include community-based DOT [50,51,52], home delivery and multi-period dispensing for self-administered therapy [53, 54]. More recently, digital adherence technologies (DAT) have emerged [55,56,57]. These include video-DOT [58, 59], SMS-based remote monitoring tools, such as 99DOTS [60], and Medication Event Reminder Monitors [61]. These tools remain underutilized given the limited, discordant evidence on the impact of DATs on clinical outcomes, incremental treatment costs and patient-centeredness of care [62,63,64,65].

With respect to optimizing private sector TB care, direct medical costs could be shifted to public health financing schemes. Viet Nam has set ambitious targets of achieving Universal Health Coverage through its national SHI scheme [66]. In doing so, Viet Nam has embarked on transitioning major public health programs for HIV and TB to SHI financing [67, 68]. However, the TB transition is in its infancy and thus continues to face challenges [69] and the current national SHI scheme offers suboptimal protection [70]. Nevertheless, the principle could conceivably be applied to the private sector as well to reduce the financial burden of treatment for patients [71, 72]. This is particularly needed for informally employed individuals who comprised one-third of our sample. Their options for treatment tend to be restricted by their limited job security, which may force them to seek out costly private sector care as a form of social protection, despite the premium it commands. It is noteworthy that regional precedence exists. In the healthcare systems of some Asian countries, privatization of TB care and pay-for-performance schemes have task shifted a portion of the TB caseload to the private sector [73, 74].

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