Poverty Sustains Tuberculosis 

This analysis is authored by Norah Owaraga, the Managing Director of CPAR Uganda Ltd and the Social Scientist for the Tuberculosis: Empowering the Nations’ Diagnostics Efforts (TWENDE) Consortium. This analysis is primarily based on the country profiles that are published in the 2015 Global Tuberculosis Report and on country statistics that are published online by the World Bank.  

Considering that tuberculosis (TB) is among infectious diseases that are transmitted through the air, it is logical to expect that nations would consider its treatment and control of utmost priority. One would not expect, for example, inconsistency between a country’s ability to pay – in this context measured by its gross domestic product (GDP) per capita and the country’s per capita provisioning for TB control. This however seems the case. Take for instance the three East African (EA) countries – Tanzania, Kenya and Uganda - that are among the 22 high TB disease burdened countries (TB countries) - and are the TWENDE TB research counties in 2016 and 2017. 

Uganda with the lowest GDP per capita - US$ 711 – in 2014 better funded its National TB Programme as compared to Kenya and Tanzania. Uganda’s 2014 budget, US$ 24 million, for its National TB Programme (TB Budget) was 79 percent funded - 10 percent from own resources and 69 percent from external sources. Uganda’s TB prevalence – the number of cases of TB in a population – in 2014 was 60 thousand, which means that Uganda’s 2014 funded TB budget provisioned average funding of US$ 316 per TB case. 

Kenya, in comparison, with a GDP per capita of US$ 1,345 in 2014, the highest GDP per capita among the TWENDE research countries that was nearly double that of Uganda, funded 26 percent of its 2014 TB budget from own resources and 28 percent from external sources; meaning that 46 percent of Kenya’s TB budget was not funded. Kenya’s TB prevalence in 2014 was 120 thousand cases. Even though Kenya’s 2014 TB budget was US$ 45 million, only 54 percent of it was funded; meaning that its 2014 funded TB budget provisioned average funding of US$ 203 per TB case - US$ 113 less than what Uganda provisioned per case. The 2014 TB budget for Tanzania, US$ 67 million, was 100 percent not funded - this for a country with a 2014 TB prevalence of 270 thousand cases and that had a GDP per capita of US$ 924 in 2014. 

Why is it the case that the two TWENDE research countries with higher GDP per capita had significantly larger proportions of their 2014 country TB budgets unfunded in comparison to the one that had a lower GDP per capita?  Is it because Uganda had a lower GDP per capita in 2014 that its TB budget received higher external funding than did Kenya’s? Why was the TB Budget for 2014 for Tanzania 100 percent unfunded? Do the funding allocations to country TB budgets explain TB prevalence in-country? Is Uganda’s lower 2014 TB prevalence the case because its 2014 TB budget was 79 percent funded? The 2014 TB prevalence for Kenya, was it so because Kenya’s TB budget was only 54 percent funded? Was Tanzania’s high 2014 TB prevalence occasioned by the fact that its TB budget was 100 percent unfunded? These and many other similar questions need asking, need answering, and are of interest to TWENDE.    

No doubt, TB is alive and well and is presenting danger to billions of people world over. The 22 TB countries in the world were home to a combined population of nearly 4.6 billion people in 2014. Nine of those 22 TB countries are in Africa and in 2014 were home to a combined population of 580 million people. In addition to the three EA TWENDE research countries, the nine African TB countries include: Democratic Republic of Congo (DR Congo), Ethiopia, Mozambique, Nigeria, South Africa, and Zimbabwe. 

The majority of the 22 TB countries, 11 of them, are located in Asia and in 2014 the 11 Asian TB countries were home to over 3.6 billion people. Among the 11 Asian countries are the two densely populated countries - China with a population of about 1.4 billion people and India with a population of about 1.3 billion people. The other nine TB countries in Asia are: Afghanistan, Bangladesh, Cambodia, Indonesia, Myanmar, Pakistan, Philippines, Thailand and Vietnam. The remaining two of the 22 TB countries are: Russia which is located in Eurasia and in 2014 had a population of 143 million people; and Brazil which is located in South America and in 2014 had a population of 206 million people. None of the 22 TB countries of 2014 are of North America and of Europe.

The 22 TB countries in 2014 had combined TB prevalence of over 10.2 million cases. The majority of those TB cases, nearly 7.8 million, were from the 11 Asian TB countries. Of those cases from the 11 Asian TB countries, the majority were from India – 2.5 million, Indonesia – 1.6 million and China – 1.2 million. The nine African TB countries in 2014 had TB prevalence of over 2.2 million cases; of which the highest numbers were from Nigeria – 590 thousand, DR Congo – 400 thousand and South Africa – 380 thousand. Brazil had TB prevalence of 110 thousand and Russia of 160 thousand.

One finds it surprising that countries such as Russia with a GDP per capita of US$ 13,011 and Brazil with a GDP per capita of US$ 11,734 are among the 22 TB countries, together with ‘poorer’ countries such as DR Congo with a GDP per capita of only US$ 442. Be that as it may, however, in 2014 Russia’s TB budget was nearly 1.9 billion and it was fully funded by Russia. This means that for its 160 thousand TB cases in 2014, Russia’s TB budget made funding provision of US$ 11,838 per case, more than 37 times Uganda’s provision per TB case. Brazil’s TB budget was US$ 77 million, of which it funded 72 percent and only one percent was externally funded; meaning that 27 percent of Brazil’s 2014 TB budget was not funded. For its 110 thousand TB cases in 2014 Brazil’s funded TB budget provisioned US$ 511 per person – 23 times less than what Russia provisioned per TB case, but nearly three times Kenya’s provision per TB case.

The 11 Asian TB countries, in comparison, in 2014 had a combined TB budget of over US$ 1.1 billion; of which 25 percent was funded from the countries’ own funds, 41 percent was funded from external funding sources, and 34 percent was not funded. The Asian TB countries’ funded budget provision to their 7.8 million cases in 2014, therefore, was an average of US$ 110 per TB case – nearly 108 times less than what Russia provisioned per TB case and five times less than what Brazil provisioned per TB case. 

It should be noted, however, that among the 11 Asian TB countries, India’s TB budget, US$ 261 million, was fully funded – 46 percent by India and 54 percent externally – making a provision of US$ 104 per TB case for India. Whereas, China’s TB budget, US$ 340 million, was not fully funded – eight percent was not funded – it was funded 90 percent by China and only two percent came from external sources. In 2014, therefore, China made a funded budget provision of U$ 261 per TB case; the highest provision per case among the 11 Asian TB countries.

When it comes to Africa, the nine TB countries in 2014 had a combined TB budget of 806 million. Of that budget, only 18 percent was funded by the nine countries, 38 percent was externally funded, and the bulk – 44 percent – was not funded. The nine African TB countries’ funded TB budgets in 2014 provisioned on average US$ 208 per TB case for their over 2.2 million TB cases.  Whereas, the nine African TB countries’ average provision per TB case in 2014 was double the average provision per TB case of the 11 Asian TB countries, it is important to remember that the average provision for the nine African TB countries was significantly lower, on grounds that the 2014 Tanzania TB budget was100 percent not funded. 

Among the nine African TB countries is Nigeria, a country generally considered ‘richer’ among other African countries in GDP per capita terms. Yes, surprisingly, 68 percent of Nigeria’s 2014 TB budget was not funded and yet Nigeria with its GDP per capita of US$ 3,212 had the second highest GDP per capita in 2014 among the nine African TB countries, exceeded only by South Africa which had a 2014 GDP per capita of US$ 6,630. Nigeria, moreover, funded only 13 percent of its TB budget, while funding from external sources covered 19 percent of the Nigeria’s TB budget.

A pattern emerges which indicates that continents and countries are giving TB control different priority levels as can be deduced from both their TB budget allocations, in the first place, and what percentage of the TB budgets are actually funded. The country priorities are seemingly not always determined by the ability to pay – material wealth or poverty. Countries with higher GDP per capita have in some instances allocated less budget provisions per TB case. However, even when countries have allocated significant TB budget allocations, such as is the case with Russia, TB prevalence seems sustained. Why so? 

One cannot assume that the entire TB budget provision per capita actually directly reaches the TB patients who most need it. In the context of Uganda, for example, funding for its National TB Programme is intended to cover costs for policy making, advocacy, communication, production of technical guidelines, production of operational guidelines, procurement of drugs and supplies, distribution of drugs and supplies, and more. Financial management for health care in many sub-Saharan African countries, such as in Uganda, is often baffling, indeed. With significant proportions of budgeted funds allocated to cover administration costs and lesser proportions allocated to procure medical human resources, materials and drugs. 

In Uganda, for example, medical staff are reported used to doing their work, including handling infectious patients, without wearing the necessary protective gear. They have gotten used to the risky practice, because it is often the case that the necessary protective gear is not procured, because it was likely considered priority to cover other non-medical staff related administrative costs – such as a powerful car for the administrator. Health care medical professionals in sub-Saharan Africa, as is the case in Uganda, are often underpaid and overworked. The swift explanation given for this maladministration often revolves around explanations that insinuate the view of that is all the funds provided could afford – few numbers of medical personnel handling huge amounts of work. 

One of Uganda’s famous doctors, Dr. Lukwiya, for example, is believed to have forgotten to wear his goggles because he was groggy after having been woken out of bed and presumably after having worked for long hours prior. Without his goggles he likely came into contact with a nurse who had contracted Ebola, likely because the nurse had not worn the proper protective gear. By that simple mistake – a momentary lapse, likely because of fatigue, Dr. Lukwiya contracted Ebola and he died from it. Perhaps, if there had been more medical personnel working with Dr. Lukwiya and as qualified as he was then perhaps he would not have been put in the position that caused him to have a momentary lapse that cost him his life.

There are other additional determinants of TB prevalence, which seem also related with poverty, but in this case at individual and household levels. Practitioners (Wulf 2014) have concluded that TB sustains in ‘richer’ countries, such as Russia, India and South Africa, not because of insufficient budget allocations per se, but because of income inequality and marginalisation in service provision. Whereas, national TB budgets may be well provided for, it is how these budgets are distributed within a country and a region that matters. 

If, as it is the case in Uganda, for example, in some cases TB diagnostic facilities and treatments are located great distances away from where the patients reside, then the challenges of accessing diagnosis and treatment become a factor in determining TB prevalence. Patients already weakened by the disease may not seek medical care on grounds of incapacitation – distance too long to walk, ride a bike or afford taxi/bus fare; or a child’s school fees is needed urgently. Even patients not yet adversely weakened by the disease may delay testing on similar grounds; sadly perpetuating the cycle - for when they do decide to get tested they may already be adversely weakened and with permanent damage to their internal organs. TWENDE is interested in exploring how income inequalities and marginalisation in service provision may be contributing to TB prevalence.

As nations make decisions about budget allocations and funding for TB, similarly, at household level families do so as well. TWENDE is interested in exploring the social cultural determinants of decisions at household level that facilitate quick detection and treatment of TB or that delay the detection of TB, if at all; and in enabling treatment for family members, if at all. How are household-level decisions contributing to access and completion of TB treatment or not? How are household-level decisions contributing to development of multi-drug-resistant TB, extensively drug-resistant TB and totally drug-resistant TB, on grounds of TB patients’ failure to complete treatment for whatever reason? What are the economic as well as cultural drivers of household decision making in relation to TB? TWENDE is interested to research these and many other similar questions.

TWENDE is convinced that its study shall contribute to a deeper understanding of how material poverty and also seeming poverty of the mind – deduced from TB budget allocation decision making - impact on diagnosis and treatment of TB. TWENDE is therefore delighted of the opportunity that the grant funding that it has received from the European & Development Countries Trials Partnerships (EDCTP) affords it to conduct research in EA that will make a contribution towards kicking TB out of the region, Africa and the world. 

Works Cited

World Health Organisation. Global tuberculosis report. Annual Report, World Health Organisation, 2015.

Wulf, Andreas. "Systemic failure ." Development and Cooperation, 2014: Vol. 41.2014:1: 17-18.