Abstract
BackgroundDrug resistance is a growing challenge to tuberculosis (TB) control worldwide, but particularly salient to countries such as Myanmar, where the health system is fragmented across the public and private sector. A recent systematic review has identified a critical lack of evidence for local policymaking, particularly in relation to drivers of drug-resistance that could be the target of preventative efforts. To address this gap from a health systems perspective, our study investigates the healthcare-seeking behavior and preferences of recently diagnosed patients with drug-resistant tuberculosis (DR-TB), focusing on the use of private versus public healthcare providers.MethodsThe study was conducted in ten townships across Yangon with high DR-TB burden. Patients newly-diagnosed with DR-TB by GeneXpert were enrolled, and data on healthcare-seeking behavior and socio-economic characteristics were collected from patient records and interviews. A descriptive analysis of healthcare-seeking behavior was followed by the investigation of relationships between socio-economic factors and type of provider visited upon first feeling unwell, through univariate logistic regressions.ResultsOf 202 participants, only 8% reported first seeking care at public facilities, while 88% reported seeking care at private facilities upon first feeling unwell. Participants aged 25–34 (Odds Ratio = 0.33 [0.12–0.95]) and males (Odds Ratio = 0.39 [0.20–0.75]) were less likely to visit a private clinic or hospital than those aged 18–24 and females, respectively. In contrast, participants with higher income were more likely to utilize private providers. Prior to DR-TB diagnosis, 86% of participants took medications from private providers. After DR-TB diagnosis, only 7% of participants continued to take medications from private providers.ConclusionIn urban Myanmar, most patients shifted to being managed exclusively in the public sector after being formally diagnosed with DR-TB. However, since the vast majority of DR-TB patients first visited private providers in the period leading to diagnosis, related issues such as unregulated quality of care, potential delays to diagnosis, and lack of care continuity may greatly influence the emergence of drug-resistance. A greater understanding of the health system and these healthcare-seeking behaviors may simultaneously strengthen TB control programmes and reduce government and out-of-pocket expenditures on the management of DR-TB.
Highlights
Drug resistance is a growing challenge to tuberculosis (TB) control worldwide, but salient to countries such as Myanmar, where the health system is fragmented across the public and private sector
Individual beliefs and preferences, as well as household social and financial constraints, can lead to suboptimal risk-taking, healthcare-seeking and compliance-related behaviors, the consequences of which may be further exacerbated by weaknesses in the underlying health system; for instance, poor health literacy coupled with limited access and high prices can lead to delays in diagnosis and treatment [5,6,7]
As funding increases for infectious disease control in Myanmar, this research provides initial evidence for policy making and resource allocation decisions [10, 11]
Summary
Drug resistance is a growing challenge to tuberculosis (TB) control worldwide, but salient to countries such as Myanmar, where the health system is fragmented across the public and private sector. In most of these countries, government spending on health per capita is relatively low, and out-of-pocket expenditures exceed 15% of total healthcare costs (well over the suggested benchmark threshold for universal health coverage) [1, 3] These and other systemic barriers - such as high costs of formal diagnosis and treatment; limited accessibility; poor management and infrastructure; and weak regulatory oversight - result in health systems that are already overstrained yet faced with a growing and increasingly complex burden of diseases, creating ideal conditions for the continued rise of drug-resistance [4]. Lack of patient motivation to comply with treatment, combined with low levels of monitoring will lead to treatment failure and contribute to the emergence of DR-TB [8, 9]
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