In China, over 130,000 people die from tuberculosis (TB) each year and in 2004, 140,000 people were estimated to have multidrug resistant tuberculosis (MDR TB), about one third of the total worldwide. TB treatments need to be taken correctly for patients to recover from the disease and prevent MDR TB from developing. It is therefore particularly important that people are able to complete a full course of treatment and that the health systems that are administering the drugs are able to supply full courses of treatment. If patients are charged for TB treatment, this might reduce completion rates, particularly amongst the poor. In the 1980's the Chinese government decentralised the health system and reduced funding for health facilities. Health services were expected to generate revenue and manage surpluses. Whilst government controlled the price for basic health care, they also established a margin for drug sales so facilities could generate income and survive. These initial reforms meant TB patients were charged like everyone else. With increased TB incidence in the 1990's, thought to be related to rural-urban migration, the government abolished fees for TB diagnosis and treatment. Despite this, providers have found ways of generating revenue from TB patients (prescribing drugs beyond the period of free treatment, follow-up X-rays, blood tests and the prescription of liver protection and ancillary drugs). All of these require payment and are in addition to the package of free care provided in the national TB programme. We sought to understand the impact of patient medical costs on adherence to TB treatment in China. We conducted a systematic review to summarise reliable evidence on costs of TB treatment, estimates of adherence and the potential impact of charging on treatment completion in China. We found that despite a policy of free drug treatment for TB in China, health services charge all income groups, and costs are high. Adherence to a full course of treatment measured in cross sectional surveys is often low, and the cumulative failure to adhere is likely to be much higher. These findings may be relevant to those concerned with the development and spread of multi-drug resistant TB. New strategies need to take this into account and ensure that patients are able to take and afford a full course of treatment.
BMC Public Health (2011), 11:393 [doi:10.1186/1471-2458-11-393]