Spatial distribution of tuberculosis in Cochabamba, socioeconomic determinants and catastrophic costs for households

Socioeconomic variables contribute to the burden and the spread of the tuberculosis, especially in developing countries. Likewise, patients with tuberculosis usually incur large costs directly related to their disease. Additional indirect costs also increase the economic burden of households creating barriers of access and adherence that can affect the healing of patients. The objective of our thesis was to determine the distribution of tuberculosis, its relationship to socio-economic determinants and assess the socio-economic consequences for patients and their households affected by the disease in the department of Cochabamba, Bolivia. Therefore, on the one hand we conducted an ecological study to evaluate the spatial distribution of tuberculosis and its relationship with socioeconomic determinants and the other hand we conducted a cross-sectional study with retrospective data collection to determine the socioeconomic impact of TB on patients and their households. We found that each region of the Department showed different values and characteristics regarding not only the incidence of tuberculosis but also regarding geography and socioeconomic variables, reflecting different realities in the five regions. The distribution pattern of the incidence of tuberculosis highlighted a high incidence in the Tropicals Regions, a moderate incidence in the Metropolitans Regions and a low incidence in the Valleys, Southern Cone and Andean Regions. The relationship between the incidence of tuberculosis and socioeconomic variables was also different between Regions. However, the variable "not homeowner" correlated positively with the incidence of tuberculosis in each Region. This variable has a very important link with the economic situation of households, because people who do not have their own home go to rental contracts that are usually associated with precarious conditions and the overcrowding of people, increasing risk of tuberculosis contamination. Likewise, we found that patients with TB treated in the health services network of Cochabamba, Bolivia, face a great financial burden as a result of the disease. Before the beginning of the diagnosis when seeking health care, more medical direct costs are observed, especially by radiography and medicines, these costs decrease during treatment, probably because the coverage of the health system allows avoiding these costs when the patient is already diagnosed. During the treatment, the most important costs were those related to transport and food due to the administration of the DOTS, due to the fact that many people have to travel long distances and even consume food outside the home to receive their treatment in the health center. In addition, there are costs for nutritional supplements and additional foods to the regular diet that patients must incur to improve their general condition. Indirect costs were the highest in the entire TB episode, mainly due to the loss of income due to TB especially in MDR-TB patients. Almost half of patients suffer a catastrophic cost, especially those who came from an urban province, those who were older than 55 years, and those having a low economic income. Regarding the measures to be taken, due to the differences in the distribution of the disease in the different regions, adapted actions must be developed for each one of them. For the disease control, the epidemiological surveillance system must be adapted to each territorial base, using an active detection strategy in regions where the incidence is higher. Our study reports a relationship between the disease and "not homeowner", this finding shows that tuberculosis is associated to the precariousness conditions and in specifically associated to the overcrowding of people. In this sense, many of bad conditions of people can be improved with an intersectoral approach focusing the action on the socio-economic determinants to improve living conditions through primary prevention measures, like the implement social housing programs, improve the educational conditions of the population and improve the nutritional status of the vulnerable population. Regarding costs related to tuberculosis when seeking health care, the public health system should take charge of patients in a timely manner, especially prioritizing the care of patients with suspected tuberculosis. In relation the costs during treatment, since these costs are indirect related to food and transportation, it is necessary to develop food and a transportation subsidy programs. Public policies must also be generated to achieve labor immobility until healing and implement protection programs to population from the economic and health effects of contracting TB, since indirect costs are the highest of the entire TB episode, mainly due to loss of income.