Implementing a “free” tuberculosis (TB) care policy under the integrated model in Jiangsu, China: practices and costs in the real world

BACKGROUND In the 1990s, China introduced a "free" tuberculosis (TB) care policy under the national TB control program. Recently, as a part of a new TB diagnosis and treatment model, it has been recommended that the integrated model scale up. This paper examines whether or not TB designated hospitals in the selected project sites have provided TB care according to the national and local guidelines, and analyzes the actual practices and expenditures involved in completing TB treatment. It also explores the reasons why "free" TB care in China cannot be effectively implemented under the integrated model. METHODS This study was conducted in three counties of Zhenjiang city, Jiangsu province. Mixed methods were used, which comprised reviewing the national and local TB control guidelines, conducting TB patient surveys, collecting TB inpatient and outpatient hospital records, and conducting qualitative interviews with stakeholders. Descriptive statistics were used for quantitative data analysis across counties and in order to compare patients who received only outpatient care and those who received both outpatient and inpatient care. The chi-square test and analysis of variance were performed where necessary. Qualitative data were analyzed using the framework approach. RESULTS Although the national TB care guidelines recommend outpatient care as a basis for TB treatment in China, we found high hospital admission rates for TB patients ranging from 39 % in Yangzhong county to 83 % in Dantu county. Almost all outpatient TB patients paid for lab tests and over 80 % paid for liver protection drugs and around 70 % paid for image examinations. These three components accounted for three-quarters of the total outpatient expenditure. For patients who received only outpatient care, the total expenditure upon completion of TB treatment was on average 1,135 Chinese yuan. For patients who received outpatient and inpatient care, the total expenditure upon completion of TB treatment was 11,117 Chinese yuan. CONCLUSION The "free" TB care policy under the integrated model has not been effectively implemented in China. There has been substantial spending on non-recommended services, examinations, and drugs for TB treatment.