Lönnroth Knut, Aung Tin, Maung Win, Kluge Hans, Uplekar Mukund
TB Strategy and Health Systems, Stop TB Department, World Health Organization, 20 Avenue Appia, CH-1211 Geneva, 27, Switzerland.
Health Policy Plan. 2007 May;22(3):156-66. doi: 10.1093/heapol/czm007. Epub 2007 Apr 12.
This article assesses whether social franchising of tuberculosis (TB) services in Myanmar has succeeded in providing quality treatment while ensuring equity in access and financial protection for poor patients. Newly diagnosed TB patients receiving treatment from private general practitioners (GPs) belonging to the franchise were identified. They were interviewed about social conditions, health seeking and health care costs at the time of starting treatment and again after 6 months follow-up. Routine data were used to ascertain clinical outcomes as well as to monitor trends in case notification. The franchisees contributed 2097 (21%) of the total 9951 total new sputum smear-positive pulmonary cases notified to the national TB programme in the study townships. The treatment success rate for new smear-positive cases was 84%, close to the World Health Organization target of 85% and similar to the treatment success of 81% in the national TB programme in Myanmar. People from the lower socio-economic groups represented 68% of the TB patients who access care in the franchise. Financial burden related to direct and indirect health care costs for tuberculosis was high, especially among the poor. Patients belonging to lower socio-economic groups incurred on average costs equivalent to 68% of annual per capita household income, with a median of 28%. However, 83% of all costs were incurred before starting treatment in the franchise, while 'shopping' for care. During treatment in the franchise, the cost of care was relatively low, corresponding to a median proportion of annual per capita income of 3% for people from lower socio-economic groups. This study shows that highly subsidized TB care delivered through a social franchise scheme in the private sector in Myanmar helped reach the poor with quality services, while partly protecting them from high health care expenditure. Extended outreach to others parts of the private sector may reduce diagnostic delay and patient costs further.
本文评估了缅甸结核病服务的社会特许经营模式是否成功提供了优质治疗，同时确保了贫困患者在获得服务方面的公平性以及经济保障。研究确定了从属于该特许经营模式的私人全科医生处接受治疗的新诊断结核病患者。在开始治疗时以及随访6个月后，对他们进行了关于社会状况、就医行为和医疗费用的访谈。利用常规数据确定临床结果，并监测病例通报趋势。在研究的乡镇中，向国家结核病规划通报的9951例新痰涂片阳性肺结核病例中，特许经营机构贡献了2097例（21%）。新涂片阳性病例的治疗成功率为84%，接近世界卫生组织85%的目标，与缅甸国家结核病规划中81%的治疗成功率相似。社会经济地位较低的群体占在该特许经营模式下获得治疗的结核病患者的68%。结核病直接和间接医疗费用造成的经济负担很高，尤其是在贫困人口中。社会经济地位较低的患者平均费用相当于家庭人均年收入的68%，中位数为28%。然而，所有费用的83%是在特许经营机构开始治疗前“寻医问药”时产生的。在特许经营机构接受治疗期间，医疗费用相对较低，社会经济地位较低的人群这一费用占人均年收入的中位数比例为3%。这项研究表明，缅甸通过私营部门的社会特许经营计划提供的高补贴结核病护理有助于为贫困人口提供优质服务，同时部分保护他们免受高额医疗费用的影响。将服务扩展到私营部门的其他领域可能会进一步减少诊断延误和患者费用。
