Sidharta Sucitro Dwijayana, Yin Jason Dean-Chen, Yoong Joanne Su-Yin, Khan Mishal Sameer
Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore.
Center for Economic and Social Research, University of Southern California, 1909 K St NW, Suite 530, Washington, DC, 20006-1101, USA.
BMC Health Serv Res. 2018 Apr 11;18(1):276. doi: 10.1186/s12913-018-3077-y.
Drug 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.
The 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.
Of 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.
In 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.
耐药性对全球结核病控制构成了日益严峻的挑战，对于缅甸等国家而言尤为突出，因为该国卫生系统在公共和私营部门之间分散。最近的一项系统评价发现，当地政策制定严重缺乏证据，特别是在耐药性驱动因素方面，而这些因素可能是预防措施的目标。为了从卫生系统角度填补这一空白，我们的研究调查了最近确诊的耐药结核病（DR-TB）患者的就医行为和偏好，重点关注私立与公立医疗服务提供者的使用情况。
该研究在仰光市十个耐药结核病负担较高的镇区进行。纳入通过GeneXpert新确诊为耐药结核病的患者，并从患者记录和访谈中收集就医行为和社会经济特征数据。在对就医行为进行描述性分析之后，通过单因素逻辑回归研究社会经济因素与首次感到不适时就诊的医疗机构类型之间的关系。
在202名参与者中，只有8%的人报告首次在公共医疗机构就诊，而88%的人报告首次感到不适时在私立医疗机构就诊。年龄在25 - 34岁的参与者（比值比 = 0.33 [0.12 - 0.95]）和男性参与者（比值比 = 0.39 [0.20 - 0.75]）分别比18 - 24岁的参与者和女性参与者更不可能去私立诊所或医院就诊。相比之下，收入较高的参与者更有可能使用私立医疗服务提供者。在耐药结核病诊断之前，86%的参与者从私立医疗服务提供者处获取药物。在耐药结核病诊断之后，只有7%的参与者继续从私立医疗服务提供者处获取药物。
在缅甸城市地区，大多数患者在被正式诊断为耐药结核病后转向仅在公共部门接受治疗。然而，由于绝大多数耐药结核病患者在确诊前首先就诊于私立医疗服务提供者，护理质量监管不力、诊断可能延迟以及缺乏护理连续性等相关问题可能会极大地影响耐药性的出现。对卫生系统和这些就医行为有更深入的了解，可能会同时加强结核病控制项目，并减少政府和患者在耐药结核病管理方面的自付费用。
