Transformations and the challenge of TB control in

RussiaFirst Global Symposium on Health

Systems Research

17th November 2010

Richard Coker

Professor of Public Health, London School of Hygiene & Tropical Medicine

A short history of man and EID

Time

Po

pu

latio

n

Hunter, Tropical climes

Agriculture, Population growth. Established reservoirs of infection

Trade routes develop, armies, explorers

Biological understanding of disease

Modification of agents of disease,‘GLOBALISATION’

Seasonality of admission and discharge

Net monthly balance of admission and discharge, simulated

Ju

ne

July

August

Septe

mb

er

Octo

ber

Novem

ber

Decem

be

r

Jan

uary

Febru

ary

Marc

h

April

May June

July

Au

gust

Sep

tem

ber

Octo

ber

Novem

ber

De

cem

ber

January

Feb

ruary

Marc

h

Ap

ril

May

June

Ju

ly

August

Se

pte

mber

Octo

ber

No

vem

ber

Decem

be

r

Ja

nuary

Fe

bru

ary

Marc

h

April

Ma

y

Ju

ne

July

Augu

st

Sep

tem

ber

Octo

ber

Nove

mbe

r

Decem

ber

-120.0

-70.0

-20.0

30.0

80.0

Months in 1998-2001

Esti

mate

d d

iffe

ren

ce b

etw

een

ad

mis

sio

n a

nd

sis

ch

arg

e

Hospitals admit more patients in the cold seasons and discharge patients in spring and in summer months. The unusual prevailing discharge in Decembers is related to the retrospective payment system

Eur J Public Health 2005; 15: 350-4.

40 years after effective interventions developed why is a TB control in Russia so inefficient?

Energy and macronutrient provision at City Hospital No. 1, Samara, 1997-2002, compared to Federal Ministry of Health norms and 1986

provision

0

100

200

300

400

500

600

700

Norm 1986 1997 1998 1999 2000 2001 2002

Esti

mate

d i

nta

ke (

g/d

ay)

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

En

erg

y i

nta

ke (

kcal/

day)

Carbohydrate Protein Fat Energy

Resource allocation and possible programme-specific indicators

33.8% 34.7% 34.2%

67.4%

11.6%

19.5%

12.6%

10.3%

19.1%

16.1%

3.4%

1.2%

11.2%

0.0%

23.7% 17.6% 21.4%

13.5%

8.5% 10.9% 7.9%1.5%

7.3%

12.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1999 2000 2001 2002 (est)

Year

Spe

ndin

g fr

om h

ealth

insu

ranc

e bu

dget

Facility maintenance

Repair and utility

Investments

Meals

Drugs and medicalsupplies

Salary+Tax

Coker RJ, Dimitrova B, Drobniewski F, Samyshkin Y, Pomerlau J, Hohlova G Y, Skuratova N, Kuznetsov S, Fedorin I, Atun R. Health system frailties in tuberculosis service provision in Russia: an analysis through the lens of formal nutritional support. Public Health 2005; 119: 837-43

Cost of case management of TB in Russia

Costs are spread across a number of years starting from treatment and shifting to managing chronic and social conditions

Costs are driven by hospitalisation, both for BK+ and BK- cases.

Health Policy Plan 2006; 21: 353-64

Cumulative LoS in TB hopsitals

Bull WHO 2005; 83: 217-23

1 11

21 31

41 51 61

71 81

91 101

111

121

131

141

151

161

171

181

191

201

211

221

231

241

251

261

271

281

291

301

311

321

331

341

351

361

Cumulative days in hospital per patient over three years : 1999-2001

Long hospitalisations

0

5

10

15

20

25

265

268

271

274

277

280

283

286

289

292

295

298

301

304

307

310

313

316

319

322

325

328

331

334

337

340

343

346

349

352

355

358

361

364

days per patients

Pat

ien

ts in

19

99-

200

1

Correlation between bed numbers and bed occupancy

– unrelated to clinical need

Eur J Public Health 2007; 17: 98-103.

Patterns of high bed capacity, lengthy hospital stays and high bed occupancy did not differ between DOTS and non-DOTS regions.

Eur J Public Health 2007; 17: 98-103.

Marked inefficiencies persist despite clinical interventions

that work because:• Financial incentives for hospitalisation• Tariffs linked to DRG (linked to cure

definitions)• Highly verticalised TB programmes• Anxiety surrounding ‘de-professionalisation’

and loss of clinical autonomy• International support focused on clinical

management, implementation of DOTS, and neglected health systems and integration

Context matters

Reflections

• Do HS impediments to contribute to worsening TB control?– December releases?– Formal nutritional deficit?– Nosocomial spread?– Interactions with HIV?

• Impact of economic, political and social transformations on TB? (and vice versa)

• Prospects?