WHO experts lamented that the diagnosis and treatment of the disease is not complicated, but it is a shame for mankind to have such a high incidence.
Writing | Xiaoyan Chen
Source | “Medical Community” Official Account
Amid the global pandemic of the novel coronavirus, there is only one day a year when the world’s eyes will be on the infectious disease of tuberculosis – March 24, World Tuberculosis Day.
Compared to the fact that the new coronavirus first appeared in the world more than two years ago, tuberculosis is almost as old as human history, and to date, it remains one of the world’s deadliest infectious disease killers. According to the World Health Organization (WHO), in 2020, 9.9 million people worldwide fell ill with tuberculosis and 1.5 million people died of tuberculosis. According to WHO estimates, the number of people with latent tuberculosis infection in the world is close to 2 billion.
China ranks second among the 30 countries with a high burden of tuberculosis, just below India. According to the “2021 Global Tuberculosis Report” released by WHO, the number of new tuberculosis cases in China in 2020 will be about 842,000, and the number of deaths from HIV-negative tuberculosis will be about 30,000.
The theme for this year’s World TB Day is “Life First, All In, End TB”. Around this theme, the Social Media Research Center of Peking University recently held an online seminar on “coordinating multiple forces to reduce the burden of tuberculosis patients”, inviting industry experts to discuss the challenges and responses of tuberculosis prevention and control, and measures to reduce the burden of tuberculosis patients. .
Picture from WHO official website
Falling in the face of “the disease of the poor”,
A disgrace to humanity
TB has long been labeled a “poor man’s disease.” In the long struggle with human beings, this germ has found the safest host – the poor.
Both globally and in China, tuberculosis is mainly found in economically underdeveloped rural areas. Low-income families, low-income industries, and vulnerable groups such as the elderly are the main targets of TB.
Poverty is a natural breeding ground for infectious diseases: living in groups, poor sanitation, and excessive physical labor can both cause tuberculosis and accelerate infection.
Picture from WHO official website
especially MDR-TB. “More than 95 percent of MDR-TB patients are very poor.” Tang Shenglan, executive deputy director of Duke University’s Institute for Global Health, found this out. To complicate matters, MDR-TB treatment costs 100 times or more than regular TB.
Professor Tang Shenglan has visited many rural areas in China since 1999, and has come into contact with many poor patients. The transportation costs and accommodation costs for medical treatment in other places are enough to make people distressed. He observed that ordinary tuberculosis patients need to be treated for 6 to 9 months, and MDR-TB patients need to be treated for nearly two years. During these two years, they may also have no economic income due to the disease.
This is one of the current challenges in TB control.
In addition, tuberculosis infection mainly occurs in less developed countries and regions, so developed countries have little interest in investing in research and development of new drugs. Currently, global R&D funding for tuberculosis is only half that of AIDS. Poor TB patients became “invisible people”. Many years ago, Professor Tang Shenglan had an exchange with some politicians and congressmen in the United States and the United Kingdom on this issue. The other party asked him: “Look at your colleagues around you, are there any tuberculosis patients?”
The only BCG vaccine was invented a century ago. For 100 years, there has been no breakthrough in the development of a tuberculosis vaccine. Before the new drug bedaquiline was approved, the field of tuberculosis had been without a new drug for 50 years. Some doctors vividly describe that using old medicine is like taking millet and a rifle and fighting an enemy that has evolved for thousands of years.
Another challenge created by poverty is patient compliance.
Professor Tang Shenglan found that many tuberculosis patients did not stop treatment until they were completely cured, and the financial burden was a very important reason.
Many patients in rural areas, after taking the medicine for three months, saw that the symptoms were relieved, so they ended the treatment and continued to work and earn money.
City workers rarely do this. They generally have better economic conditions and are guaranteed sick leave.
Chen Jiaying, director of the Center for Health Policy Research at Nanjing Medical University, also noticed this phenomenon. In his view, tuberculosis is both a “disease of the poor” and a “disease of the rich”. Patients not only have to bear the cost of medical treatment, but also increase enough nutrition to improve the body’s resistance. This is also an additional burden.
If a course of treatment is not cured and medication is used irregularly,The bacteria may evolve into drug-resistant bacteria, causing more serious consequences.
Many WHO experts also lamented that the diagnosis and treatment of tuberculosis is actually not complicated, but the current high incidence is really a shame for mankind.
From “catastrophic spend” to “zero burden”,
How far is it to go?
Reducing the burden on TB patients is the only way to reach the goal of ending TB.
In Tang Shenglan’s view, tuberculosis is not only an infectious disease, but also a public health and social issue, including the medical insurance system and social security.
So far, social security for people with tuberculosis does not appear to be robust. Even though many impoverished patients enjoy free medical treatment, they cannot avoid the additional heavy burden of transportation and accommodation costs for medical treatment. There are also thresholds, payment ratios and caps, which add 20% to 30% of the payment to patients. For low-income households, these are “catastrophic expenses.”
Medicare is also inadequate. The most stressed are MDR-TB patients. First-line drugs do not work for them. They can only resort to second-line drugs (self-paid drugs), which are not included in the medical insurance list and are expensive. Taking “linezolid” as an example, each pill costs more than 300 yuan, and patients need to take 1-2 pills per day.
According to the estimates of the World Health Organization in 2019, in my country, the catastrophic expenditure on medical and health care households due to tuberculosis accounted for 19.72% of the total sick population.
In response to these problems, some places have already started corresponding attempts. For example, civil affairs departments in some areas of Ningxia will provide patients with subsidies for transportation and missed meals to make up for the cost gap caused by medical treatment. Jiangsu Province invested 40 million yuan in special funds for the prevention and control of MDR-TB in 2020, of which 20 million were subsidized drugs. The government has successively purchased second-line drugs such as linezolid and provided them to patients for free. Anyang City, Henan Province has issued relevant policies, identifying bedaquiline and delamanid as specific drugs, and improving reimbursement standards.
Another key focus for reducing the burden on patients lies in hospitals.
Tang Shenglan believes that since the medical reform in 2009, there has been no fundamental change in the payment mechanism of doctors’ remuneration in Chinese public hospitals. The service volume and service income of each department are still linked to the income of doctors and nurses. . This incentive mechanism is currently a big problem. It may lead to over-medication and increase the financial burden on patients.
Picture from WHO official website
Chen Jiaying also put forward his own views on this issue. At present, hospitals rely on medical service income as their main source of income, and it may be difficult to have enough enthusiasm to take the initiative to prevent diseases.
As a result, he prefers reforming the way Medicare pays. Taking tuberculosis as an example, the current method of separate settlement of outpatient and inpatient settlements cannot restrain unnecessary services such as excessive hospitalization, which will increase the burden on patients and medical insurance, and is not conducive to disease prevention.
However, if the bundled payment method of “outpatient + hospitalization” for a full course of treatment is adopted, the various services and medical expenses of the patient’s full course of treatment can be calculated, and then combined with the current actual expense level to determine A reasonable full-course payment standard for each patient, thus encouraging hospitals to treat patients with the most economical and effective means.
The specific plan can be summarized into two aspects: one is to pay according to the total regional headcount budget. For example, there are 1,000 tuberculosis patients expected in a certain area, that is, the total payment of 1,000 tuberculosis patients is approved according to the payment standard, and the total payment is packaged and paid to designated medical institutions.
The second is the bundled fixed payment for outpatient and inpatient treatment based on the number of patients managed and treated. Each tuberculosis patient is paid a fixed amount for a full course of treatment, and the total payment is determined according to the number of patients treated.
Whether it is a per capita quota or a bundled quota for outpatient and inpatient services, the total payment is based on the number of cases in the base year as a reference. In some regions, the total amount even increases proportionally year by year. If there is a balance in the total (that is, the actual number of sick patients is less than the budget), the given hospital will also be rewarded proportionally. In addition, in order to ensure quality, all regions use the evaluation results of the whole process of standardized diagnosis and treatment as the basis for medical insurance settlement, and cash medical expenses according to the evaluation results.
This is a healthy way to pay for health insurance that can motivate hospitals to prevent TB. Because only when the prevention is done well, the number of patients decreases, and the medical services that need to be provided decrease, the hospital’s income will increase.
Mao Zongfu, director of Wuhan University’s Global Health Research Center, put forward a proposal to achieve “zero burden” of MDR-TB at the 2021 Two Sessions. But at present, TB prevention and control still faces many challenges. Mentioning this, Mao Zongfu’s tone was a little worried:
“Ordinary pulmonary tuberculosis, including drug-resistant tuberculosis, can be cured and recovered as long as it is detected early and treated in a timely manner. Currently, it is also an optimal window period (for tuberculosis prevention and control). If the bacillus changes further, there may be no cure in the future, and there is no cure if there is no cure, and this situation is very bad.”
Source: Medicine
Editor in charge: Zheng Huaju
Proofreading: Zang Hengjia
Plate making: Xue Jiao