The Economic Cost of Non-adherence to TB Medicines Resulting from Stock-outs and Loss to Follow-up in Kenya

Report

One of the key elements of successful tuberculosis (TB) control programs is adherence to treatment, which is a cornerstone of most international and national policies and guidelines. Non- adherence results in increased length and severity of illness, death, disease transmission, and drug resistance. This has economic consequences in terms of cost, to both individuals and the health system as a whole, as well as lost income for patients and their families.

A common cause of non-adherence is treatment interruption, which may range from short, intermittent periods of days to longer periods of weeks or months, and may even result in complete discontinuation of treatment. Treatment interruption is often due to patient-related factors—classed as loss to follow-up (LTFU)—but can also be a result of provider issues, such as stock-outs of medicines. Interventions to prevent treatment interruption are, therefore, aimed at both treatment providers and patients. On the provider side, actions include ensuring proper prescribing practices and management of side effects, providing good quality medicines, and preventing stock-outs. On the patient side, actions include interventions to encourage patients to use medicines as directed and continue treatment even when they feel better, as well as to remove barriers to treatment, such as transport costs. These actions are believed to be a good investment, but the economic savings have not been clearly defined.

Kenya is among 22 countries considered to have a high burden of TB, including multidrug- resistant TB (MDR-TB). The Kenyan Ministry of Health (MOH) has an extensive TB program that is managed by the NTLDP. The program includes directly observed treatment, short course (DOTS) for TB and DOTS-Plus for MDR-TB. In addition, the NTLDP has strategies and procedures in place to ensure and improve treatment adherence, including patient compliance incentives and supply chain management systems.

Under government devolution in 2013/14, the procurement of TB medicines became the responsibility of the county governments. However, county governments had limited capacity to procure TB medicines due to technicalities involved in the procurement process. As a result, no adult first-line TB medicines were procured for two financial years and stock-outs were a serious concern. The NTLDP, with technical support from the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program and advocacy from other stakeholders, prepared a compelling, evidence-based case to the national government and key partners. As a result, emergency funding was obtained, which averted the crisis. This situation was selected by SIAPS to illustrate the impact that this crisis could have had on morbidity and mortality, as well as the economic impact, if it had not been averted.

Like many developing countries, Kenya has had challenges with LTFU. According to NTLDP data, the average LTFU in 2014 was 4%, with Samburu and Pokot counties having the highest rates (10% and 12%, respectively) (NTLDP Annual Report, 2015).

The purpose of this study was to estimate the morbidity, mortality, and economic impact of TB treatment interruption due to stock-outs and LTFU. The results are expected to help promote the benefits of ensuring the availability of good quality medicines and of undertaking interventions to reduce LTFU.

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