Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China

Abstract

BackgroundTuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden.MethodsUsing a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding.ResultsPatients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable.ConclusionsFinancial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-017-4089-y) contains supplementary material, which is available to authorized users.

Genetic diversity and drug resistance of Mycobacterium tuberculosis in Yunnan, China

“…Yunnan belongs to the regions in China, where TB is prevalent. TB morbidity reached 6‰ in Yunnan population due to high incidence of various infectious diseases, large rural cohort, and limited medical condition . In addition, the genetic diversity of MTB was more plenty in Yunnan than in the other regions .…”

“…TB morbidity reached 6‰ in Yunnan population due to high incidence of various infectious diseases, large rural cohort, and limited medical condition. 16 In addition, the genetic diversity of MTB was more plenty in Yunnan than in the other regions. 12,17 This study aims to investigate the genetic diversity and molecular epidemiology of MTB in the Yunnan population.…”

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“…5) such as unemployment, poor TB knowledge, and having difficulties or to travel a long distance to visit health facilities [39,47]. Long-distance to health facilities was also reported by qualitative studies as a barrier to care-seeking [44,109,110,112,115,124,129,134,135,138,140,143]. In addition to physical barriers, financial insecurities and economic challenges also compounded patient delay [21, 24, 29, 34-36, 39, 46, 47, 62, 63, 65, 68, 72, 73, 79, 81, 85, 86].…”

“…Bangladesh [113,114], Brazil [127,128], Cambodia [115], China [133,134], Ethiopia [108], India [113,119], Nigeria [123], Philippines [124], Russia[135], South Africa [137][138][139][140][141][142], Tanzania [112], Zambia [125], Zimbabwe [126] Perceived stigma and discrimination at workplace, within family and the community against women, and associating TB with HIV deterred presumptive TB cases from seeking TB diagnosis and care "When someone says, 'I have TB' others will say that the person has three words [HIV].'' [141] "The person would be scared that she would lose her job and that people and friends would avoid her."…”

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“…Similarly, even among people with valid insurance, patient co‐payment (user fee) can be a barrier to early care seeking and access to treatment. Both are real issues, especially where TB services have been conventionally provided by public health outlets free of charge, and particularly serious for people with DR‐TB . Second, the integration of TB services under health insurance schemes can sometimes adversely affect the quality of TB care.…”