Nqobizitha Nkomo and his wife from Insiza District in Matebeleland South, were both diagnosed of Drug Resistant Tuberculosis (DR-TB) about a year ago. Even though they say they are feeling better, Nkomo recounts how their situation almost reduced them to beggars of some sort in their quest to sustain their treatment and recovery journey.
By Michael Gwarisa
Drug-resistant TB (DR-TB) is a form of tuberculosis which has developed resistance to the main medicines used to treat TB. This form of TB can be resistant to one or more anti-TB medicines. DR-TB has Fixed drug combinations (FDCs) where treatment for Drug resistance takes between 9 – 12 months and an intensive phase that requires 5 – 7 medicines and Continuation phase 5 and 3 medicines. For Extensively drug resistant TB, one needs up to 24 months of treatment.
Even though TB treatment is free in Zimbabwe, patients bear huge costs that at times push them into losing valuable assets. The situation is worse for unemployed and economically incapacitated individuals like Nkomo.
Our biggest challenge is food and money for transport to the hospital,” said Nkomo. “We have to ask for money from relatives in order to go to the hospital to get treatment and sometimes we feel like we are burdening people and are tempted to not ask for bus fare and probably default on treatment.”
Matabeleland is a high burden zone for infectious diseases such as TB which is Multi Drug Resistant TB and HIV with more cases coming in from Beitbridge and Gwanda as for the period 2016 to 2018 with the least notifications coming from Umzingwane.
In Zimbabwe, households incur large costs related to TB illness while seeking and receiving health care. Such costs create access and adherence barriers which affect health outcomes and increase transmission of the disease.
People with DR-TB undergo disruptive, life-altering experiences such losing their jobs and livelihoods. According to a World Health Organisation (WHO) survey of 2019, 90 percent of MDR -TB patients faced catastrophic costs compared to 79 percent of DS-TB patients.
Some of the costs TB patients incur include transport costs, x-ray costs, non-medical costs, and medical costs nutrition costs indirect costs among others.
Kudakwashe Mumhare, a female aged 34 from Gweru, stopped going to work after she had been diagnosed of DR-TB seven months ago. She says her appetite has increased since she started treatment in August 2022 and now food consumes the lion’s share in terms of household expenditure.
However, because she is now unemployed, it is now difficult to fund her appetite.
“Generally, treatment is free. However, there are transport costs included when going to the clinic and also for ECG where they check if the treatment is not affecting you in any way. You go there before you go to the clinic and then costs to go to the hospital and food. Food has been the biggest challenge for. Somehow I have developed an appetite for food and I now eat more than six meals a day. I now eat like no man’s business and at times I get off budget,” said Kudakwashe.
She says she requires between US$4 to US$5 whenever she travels for treatment and other check-ups at a clinic 3 kilometers away. Her personal food bill now hovers around US$50 to US$70 without factoring in the food that is consumed by her household.
“At the moment i am unemployed, when i fell sick, i quit my job. I have got two kids and they both need to go to school. I had to clear fees from my child’s primary school before he went for Form 1. My child uses public transport to go to school, he needs bus fare. My other child is doing Grade 2, she needs a packed lunch box. Now that i am unemployed and this is a challenge. I thank my sister and my mother who support me to ensure i meet all my bills.”
According to the Ministry of Health and Child National TB Program (MoHCC-NTP), the country has been experiencing a decline in terms of DRTB case notifications and also in the number of DR-TB patients initiated on treatment.
In 2017, the number of DR-TB notifications was 478 while that of those initiated on treatment was 442. However, in 2021, only 248 new DR-TB cases were notified and 232 initiated on treatment. The ministry says its working on efforts to Improve DR-TB Case Finding and Management and these include Revision of TB diagnostic algorithm (v.May 2022), Printing and distribution of the new algorithm, Training of health care workers, Clinicians trained on diagnosis, treatment and monitoring, Influential community leaders trained on the basics of TB to create demand for TB services in their communities and Community based volunteers trained on retrieving patients lost to follow-up.
In 2022, Zimbabwe notified a total of 242 DR-TB cases to the WHO according to the Global TB Report of 2022. According to the National TB Programme Performance Report of 2022, the majority of DR-TB cases were reported in Matabeleland South (41), Bulawayo (40), Midlands (31) and Mashonaland West (27) Provinces.
High burden of DRTB has been associated with high prevalence of HIV, highly mobile populations; particularly where cross-border migration is involved, informal mining activities such as artisanal and small-scale mining and poor adherence to TB medicines used to treat drug susceptible TB (DSTB) as well as being a contact of someone with DRTB.
Catastrophic costs refer to the use of >20% of income to seek TB care in this instance. Speaking on the catastrophic costs DRTB patients incur, the Union Zimbabwe Trust Executive Director, Dr Ronald Ncube said Catastrophic costs also arise because economic capabilities of patients are often suspended for the time they are seeking TB care services until they are well enough to work.
“With all forms of TB, clients incur catastrophic costs mainly because they need to visit a health facility more than once before they get a diagnosis, they are treated for other respiratory diseases before TB is diagnosed, and some tests are not widely available and will need to be sought in the private sector. As such, the expenses often exceed 20% of household income,” said Dr Ncube.
“DR-TB by virtue of being a more complex disease to manage has higher catastrophic costs due to more frequent visits to the health facility. Costs incurred by DR-TB patients are mostly aligned with transport and food security. They also incur high costs during the diagnosis period as they are going through tests. A study was done through the Ministry of Health and Child Care on catastrophic costs incurred by DSTB and DRTB patients and you can access it here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8519355/.
“Costs are mostly around transport to health facilities, buying food and medical supplements and supplementary tests that are done during treatment monitoring. Apart from these costs, DRTB patients lose income as they are often incapacitated to work gainfully during the course of their treatment.”
He added that If people are encouraged to present early to health facilities when they start to fall ill, this can help them as they begin treatment whilst still fit and able to work.
“Social and financial systems can also be put in place to support DRTB patients with food and transport costs for the duration of their treatment and even after they complete treatment, until they fully recuperate.”
Meanwhile, the Union Zimbabwe Trust and its consortium partners, through the Kunda-Nqob’iTB (KN-TB) programme supported by the United States Agency for International Development (USAID) is present in eight high DR-TB notifying districts. The districts include Gweru, Shurugwi, Zvishavane, Kwekwe, Chirumhanzu, Insiza, Gwanda and Mwenezi.
Through community related interventions implemented by Jointed Hands Welfare Organization, with support from Hospice Palliative Care Association of Zimbabwe, we are increasing demand for TB services through a network of supported Community Based Volunteers (CBVs), who raise awareness and screen community members for TB, referring any clients presumed to have TB symptoms to the nearest health facility for further tests. Patients diagnosed with TB and not yet resistant to treatment receive treatment adherence support and palliative care to prevent the emergence of drug resistance. Health workers across these districts have been trained on the clinical management of DR-TB to optimize clinical outcomes and prevent amplification of resistance.
“Through Baines Occupational Health Services, one of the consortium partners, community outreaches are being conducted particularly to artisanal miners across the supported districts to find missed cases of all forms of TB including DR-TB.
“Additionally, with support from the STOP TB Partnership, across 19 districts in Midlands, Matabeleland South and Bulawayo, provinces have been equipped with the latest technology for rapid drug susceptibility testing for TB, to establish the resistance profile early for timely initiation to more patient friendly all oral treatment regimens for DR-TB. The Union Zimbabwe Trust is also a sub recipient of the Global Fund grant, to institutionalize the capacity of provincial teams on use of mobile x-ray trucks to screen for TB, including DR-TB across the country. Over the past two years, close to 20,000 community members had been reached and screened for TB and linked to care.”
