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Background The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs. Methods This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs. Results We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality. Conclusions Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

OBJECTIVE: To verify the effectiveness of screening for tuberculosis (TB) on all-cause mortality and tuberculosis cases in newly diagnosed HIV-infected patients through a clinical algorithm based on recommendations of the World Health Organization. METHODS: From March 2014 to April 2016, a pragmatic randomized clinical trial was conducted with newly diagnosed and TB-free HIV-infected adults undergoing antiretroviral therapy for up to one month at a major tertiary hospital for HIV in the state of Pernambuco, Brazil. Participants were randomized into intervention and control groups using an automatically-generated random list, and followed-up for at least 6 months. The intervention group was screened for TB at hospital admission and at every follow-up visit through a series of questions addressing TB-related symptoms (cough, fever, night sweating, and weight loss). Patients presenting with any of these symptoms were referred to a pulmonologist and underwent sputum smear microscopy, sputum culture, and rapid molecular testing (GeneXpert). When at least one test result came back positive, TB treatment was initiated. In turn, if patients tested negative but presented with severe clinal symptoms, TB preventive treatment was initiated. Screening for TB was not performed systematically in the control group. The primary outcome assessed in this study was death from all causes, and secondary outcomes included sensitivity and specificity of this screening test, as well as its detection time. RESULTS: This study evaluated 581 patients, 377 in the intervention group (64.9%) and 204 in the control group (35.1%). In total, 36 patients died during the follow-up period. Of these, 26 (6.9%) were from the intervention group, reaching a cumulative mortality coefficient of 69 per 1,000 inhabitants, and 10 (4.9%) from the control group (p = 0.341), with a cumulative mortality coefficient of 49 per 1,000 inhabitants (p = 0.341).

Background Transmission dynamics, vectorial capacity, and co-infections have substantial impacts on vector-borne diseases (VBDs) affecting urban and suburban populations. Reviewing key factors can provide insight into priority research areas and offer suggestions for potential interventions. Main body Through a scoping review, we identify knowledge gaps on transmission dynamics, vectorial capacity, and co-infections regarding VBDs in urban areas. Peer-reviewed and grey literature published between 2000 and 2016 was searched. We screened abstracts and full texts to select studies. Using an extraction grid, we retrieved general data, results, lessons learned and recommendations, future research avenues, and practice implications. We classified studies by VBD and country/continent and identified relevant knowledge gaps. Of 773 articles selected for full-text screening, 50 were included in the review: 23 based on research in the Americas, 15 in Asia, 10 in Africa, and one each in Europe and Australia. The largest body of evidence concerning VBD epidemiology in urban areas concerned dengue and malaria. Other arboviruses covered included chikungunya and West Nile virus, other parasitic diseases such as leishmaniasis and trypanosomiasis, and bacterial rickettsiosis and plague. Most articles retrieved in our review combined transmission dynamics and vectorial capacity; only two combined transmission dynamics and co-infection. The review identified significant knowledge gaps on the role of asymptomatic individuals, the effects of co-infection and other host factors, and the impacts of climatic, environmental, and socioeconomic factors on VBD transmission in urban areas. Limitations included the trade-off from narrowing the search strategy (missing out on classical modelling studies), a lack of studies on co-infections, most studies being only descriptive, and few offering concrete public health recommendations. More research is needed on transmission risk in homes and workplaces, given increasingly dynamic and mobile populations. The lack of studies on co-infection hampers monitoring of infections transmitted by the same vector. Conclusions Strengthening VBD surveillance and control, particularly in asymptomatic cases and mobile populations, as well as using early warning tools to predict increasing transmission, were key strategies identified for public health policy and practice. Electronic supplementary material The online version of this article (10.1186/s40249-018-0475-7) contains supplementary material, which is available to authorized users.

BackgroundThe World Health Organization (WHO) End TB Strategy has established a milestone to reduce the number of tuberculosis (TB)- affected households facing catastrophic costs to zero by 2020. The role of active case finding (ACF) in reducing patient costs has not been determined globally. This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding (PCF), and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal.MethodsThe study was conducted in two districts of Nepal: Bardiya and Pyuthan (Province No. 5) between June and August 2018. One hundred patients were included in this study in a 1:1 ratio (PCF: ACF, 25 consecutive ACF and 25 consecutive PCF patients in each district). The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs. Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20% of their annual household income.The intensity of catastrophic costs was calculated using the positive overshoot method. The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs. Meanwhile, the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis.ResultsNinety-nine patients were interviewed (50 ACF and 49 PCF). Patients diagnosed through ACF incurred lower costs during the pre-treatment period (direct medical: USD 14 vs USD 32,P = 0.001; direct non-medical: USD 3 vs USD 10,P = 0.004; indirect, time loss: USD 4 vs USD 13,P P = 0.002) and non-medical (USD 30 vs USD 54,P = 0.022) costs among ACF patients. The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds. A lower intensity of catastrophic costs was also documented for ACF patients, although the difference was not statistically significant.ConclusionsACF can reduce patient-incurred costs substantially, contributing to the End TB Strategy target. Other synergistic policies, such as social protection, will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.

Tuberculosis (TB), the leading single infectious diseases killer globally, is driven by poverty. Conversely, having TB worsens impoverishment. During TB illness, lost income and out-of-pocket costs can become “catastrophic”, leading patients to abandon treatment, develop drug-resistance, and die. WHO’s 2015 End TB Strategy recommends eliminating catastrophic costs and providing socioeconomic support for TB-affected people. However, there is negligible evidence to guide the design and implementation of such socioeconomic support, especially in low-income, TB-endemic countries. A national, multi-sectoral workshop was held in Kathmandu, Nepal, on the 11th and 12th September 2019, to develop a shortlist of feasible, locally appropriate socioeconomic support interventions for TB-affected households in Nepal, a low-income country with significant TB burden. The workshop brought together key stakeholders in Nepal including from the Ministry of Health and Population, Department of Health Services, Provincial Health Directorate, Health Offices, National TB Program (NTP); and TB/Leprosy Officers, healthcare workers, community health volunteers, TB-affected people, and external development partners (EDP). During the workshop, participants reviewed current Nepal NTP data and strategy, discussed the preliminary results of a mixed-methods study of the socioeconomic determinants and consequences of TB in Nepal, described existing and potential socioeconomic interventions for TB-affected households in Nepal, and selected the most promising interventions for future randomized controlled trial evaluations in Nepal. This report describes the activities, outcomes, and recommendations from the workshop.

Objectives To summarize the costs of tuberculosis (TB) diagnosis and treatment in human immunodeficiency virus (HIV)-infected patients and to assess the methodological quality of these studies. Methods We included cost, cost-effectiveness, and cost-utility studies that reported primary costing data, conducted worldwide and published between 1990 and August 2016. We retrieved articles in PubMed, Embase, EconLit, CINAHL plus, and LILACS databases. The quality assessment was performed using two guidelines—the Consolidated Health Economic Evaluation Reporting Standards and the Tool to Estimate Patient's Costs. TB diagnosis was reported as cost per positive result or per suspect case. TB treatment was reported as cost of TB drugs, TB/HIV hospitalization, and treatment. We analyzed the data per level of TB/HIV endemicity and perspective of analysis. Results We included 34 articles, with 24 addressing TB/HIV treatment and 10 addressing TB diagnosis. Most of the studies were carried out in high TB/HIV burden countries (82%). The cost of TB diagnosis per suspect case varied from $0.5 for sputum smear microscopy to $175 for intensified case finding. The cost of TB/HIV hospitalization was higher in low/medium TB/HIV burden countries than in high TB/HIV burden countries ($75,406 vs. $2,474). TB/HIV co-infection presented higher costs than TB from the provider perspective ($814 vs. $604 vs. $454). Items such as "choice of discount rate," "patient interview procedures," and "methods used for valuing indirect costs" did not achieve a good score in the quality assessment. Conclusions Our findings point to the need of generation of more standardized methods for cost data collection to generate more robust estimates and thus, support decision-making process.

Aim: to conduct a systematic literature review on dengue costs in Latin America, comparing study methodologies, disease costs and the economic impact of dengue in different countries. Methods: the literature search was carried out in the following electronic databases: MEDLINE/PubMed, EMBASE and LILACS, for the period between 2004 and 2014. To make comparisons possible, the costs identified in the selected studies were converted to local currency values, adjusted to the consumer price index (2014) and converted to purchasing power parity (PPP). Results: 728 publications were identified in databases and 13 papers were selected for analysis. Nine of the thirteen studies were conducted from a societal perspective and three from a health system perspective. In most studies, indirect costs accounted for the largest percentage of total outpatient costs. In contrast, for hospitalized patients, direct medical costs showed the highest percentages. The economic impact of dengue was estimated at I$ 3.2 billion per year, ranging from I$ 1.4 to I$ 5.9 billion, when including the six sub-regions of the Americas. Conclusion: dengue represents a high cost for Latin American society and health system. Studies varied in terms of cost methodology (cost items included, such as direct medical and non-medical and indirect costs, and cost analysis) and the different epidemiological periods in which research was carried out (endemic and/or epidemic).

Objective To estimate the incremental cost of delivering intrathecal tetanus immunoglobulin compared to an intramuscular option. Methods To compare the two interventions, costs were estimated using standard cost methodology. Cost categories were personnel, overhead, consumables, antibiotics to treat infection, gases for respiratory assistance and immunoglobulin. Tetanus patients, aged 12 years or older, who were part of a randomised controlled clinical trial conducted in a referral hospital in Recife, Brazil, were allocated to two groups: a control group (58) and a study group (62). Patients allocated to the control group received 3000 international units (IU) of human immunoglobulin, with preservative, intramuscularly. The study group received the same quantity of immunoglobulin also intramuscularly plus an intrathecal dose of 1000 IU of a human immunoglobulin, free of preservatives, to prevent irritation of the meninges and avoid the need for corticosteroids. Thus, the difference between the two groups was the exclusive use of intrathecal immunoglobulin. The outcome measurements were clinical progression, hospital stay, respiratory assistance and respiratory infection. Results Delivering intrathecal immunoglobulin to patients saved a total of US$ 60 389, in a 10-day intensive care treatment, by preventing a worsening of their tetanus severity (e.g. from Grade I to Grades II, III, IV). Substantial cost saving was also observed in terms of hospital stay (US$ 173 104). Conclusions Intrathecal treatment of tetanus is cost saving. This intervention deserves consideration by doctors and decision-makers as a mean of saving resources while maintaining high-quality health outcomes. Objectif Estimer le cout supplementaire de l'administration intrathecale d'immunoglobulines antitetaniques par rapport a l'alternative intramusculaire. Methodes Les couts ont ete estimes pour deux interventions en comparaison, en utilisant la methodologie du cout standard. Les categories de couts etaient liees au personnel, aux frais generaux, aux consommables, aux antibiotiques pour traiter l'infection, aux gaz pour l'assistance respiratoire et aux immunoglobulines. Les patients atteints de tetanos, âges de 12 ans ou plus, qui faisaient partie d'un essai clinique randomise et controle mene dans un hopital de reference a Recife, au Bresil, ont ete repartis en deux groupes: un groupe temoin (58) et un groupe d’etude (62). Les patients affectes au groupe temoin ont recu 3000 unites internationales (UI) d'immunoglobulines humaines, contenant un agent conservateur, par voie intramusculaire. Le groupe d’etude a aussi recu la meme quantite d'immunoglobulines par voie intramusculaire, plus une dose de 1000 UI d'immunoglobulines humaines par voie intrathecale, sans agent conservateur, pour eviter l'irritation des meninges et le besoin de corticosteroides. Ainsi, la difference entre les deux groupes etait l'usage exclusif des immunoglobulines par voie intrathecale. Les resultats mesures etaient: la progression clinique, le sejour a l'hopital, l'assistance respiratoire et les infections respiratoires. Resultats L'administration d'immunoglobulines par voie intrathecale chez les patients a permis d’economiser un total de 60.389 US$ dans un traitement en soins intensifs de 10 jours, en evitant une aggravation de la severite du tetanos (ex: passage du Stade I aux Stades II, III, IV). Une reduction importante des couts a egalement ete observee en termes de sejour a l'hopital (173.104 US$). Conclusions Le traitement par voie intrathecale du tetanos permet des economies. Cette intervention merite d’etre consideree par les medecins et les decideurs comme un moyen d’economiser les ressources, tout en maintenant des resultats de sante de qualite. Objetivo Calcular el coste incremental de poner la inmunoglobulina antitetanica por via intratecal, comparada con la opcion intramuscular. Metodos Los costes se calcularon para dos intervenciones comparadas utilizando una metodologia estandar de costes. Las categorias de costes fueron personal, costes indirectos, consumibles, antibioticos para tratar infecciones, gases para asistencia respiratoria e inmunoglobulina. Los pacientes con tetano, con 12 anos o mas, que eran parte de un ensayo clinico aleatorizado y controlado realizado en un hospital de referencia de Recife, Brasil, se asignaron a uno de dos grupos: un grupo control (58) y un grupo de estudio (62). Los pacientes asignados al grupo control recibieron 3000 unidades internacionales (IU) de inmunoglobulina humana, con preservativo, por via intramuscular. El grupo de estudio recibio la misma cantidad de inmunoglobulina, tambien por via intramuscular, y ademas una dosis intratecal de 1000 IU de inmunoglobulina humana, libre de preservativos, para prevenir la irritacion de las meninges y evitar la necesidad de administrar corticosteroides. Por lo tanto, la diferencia entre los dos grupos era el uso de la inmunoglobulina intratecal. Los resultados medidos eran la progresion clinica, el ingreso hospitalario, la asistencia respiratoria y la infeccion respiratoria Resultados El dar inmunoglobulina intratecal a los pacientes ahorro un total de US$ 60,389, en un tratamiento de 10 dias de cuidados intensivos, al prevenir un empeoramiento en la severidad del tetano (por ej. del Grado I a Grados II, III, IV). Tambien se observo un ahorro sustancial en terminos de ingreso hospitalario (US$173,104). Conclusiones El tratamiento intratecal del tetano ahorra costes. Esta intervencion deberia ser tenida en cuenta por doctores y legisladores como un medio para ahorrar recursos a la vez que se mantiene una alta calidad en los resultados sanitarios.

Apesar dos meios para assistência adequada aos pacientes de dengue na rede de saúde, os índices de letalidade pela doença mantêm-se altos no Brasil. Visando a identificar implicações para ocorrência do óbito, este estudo avaliou a qualidade da assistência conforme grau de implantação das ações, qualidade técnico-científica da atenção e acesso aos serviços de saúde, em dois municípios do Nordeste do Brasil. Realizou-se pesquisa avaliativa, do tipo análise de implantação, tendo o óbito por dengue como evento sentinela da qualidade da assistência. Para avaliação do grau de implantação e qualidade da atenção, pontuaram-se os critérios das entrevistas e análise dos prontuários; para o acesso, procedeu-se à análise temática. Quanto à estrutura e ao processo, os serviços de saúde encontram-se parcialmente adequados (70%). Não foram encontradas barreiras geográficas e econômicas que justificassem a ocorrência dos óbitos. A qualidade técnico-científica não alcançou a adequação nos municípios (46% e 30%) e nos serviços avaliados, observando-se insuficiência no manejo clínico da dengue nos serviços de saúde. Despite the existing resources for adequate dengue patient care in the Brazilian healthcare system, the case-fatality rate for the disease is still high in the country. In order to identify factors associated with dengue-related death, this study evaluated quality of care according to the degree of implementation of specific measures, the technical and scientific quality of care, and access to health services in two municipalities (counties) in Northeast Brazil. An evaluative study of the implementation analysis type was performed, with death from dengue as the sentinel event for quality of care. To assess the degree of implementation and quality of care, the study scored the interview criteria and patient chart analysis; access was evaluated by thematic analysis. As for structure and process, the health services were found to be partially adequate (70%). No geographic or economic barriers were found to explain the occurrence of deaths. Technical and scientific quality failed to achieve adequate levels in the municipalities (46% and 30%) or in the specific services, and clinical management of dengue by the health services proved insufficient.

Background Dengue is an increasing public health concern in Brazil. There is a need for an updated evaluation of the economic impact of dengue within the country. We undertook this multicenter study to evaluate the economic burden of dengue in Brazil. Methods We estimated the economic burden of dengue in Brazil for the years 2009 to 2013 and for the epidemic season of August 2012- September 2013. We conducted a multicenter cohort study across four endemic regions: Midwest, Goiania; Southeast, Belo Horizonte and Rio de Janeiro; Northeast: Teresina and Recife; and the North, Belem. Ambulatory or hospitalized cases with suspected or laboratory-confirmed dengue treated in both the private and public sectors were recruited. Interviews were scheduled for the convalescent period to ascertain characteristics of the dengue episode, date of first symptoms/signs and recovery, use of medical services, work/school absence, household spending (out-of-pocket expense) and income lost using a questionnaire developed for a previous cost study. We also extracted data from the patients’ medical records for hospitalized cases. Overall costs per case and cumulative costs were calculated from the public payer and societal perspectives. National cost estimations took into account cases reported in the official notification system (SINAN) with adjustment for underreporting of cases. We applied a probabilistic sensitivity analysis using Monte Carlo simulations with 90% certainty levels (CL). Results We screened 2,223 cases, of which 2,035 (91.5%) symptomatic dengue cases were included in our study. The estimated cost for dengue for the epidemic season (2012–2013) in the societal perspective was US$ 468 million (90% CL: 349–590) or US$ 1,212 million (90% CL: 904–1,526) after adjusting for under-reporting. Considering the time series of dengue (2009–2013) the estimated cost of dengue varied from US$ 371 million (2009) to US$ 1,228 million (2013). Conclusions The economic burden associated with dengue in Brazil is substantial with large variations in reported cases and consequently costs reflecting the dynamic of dengue transmission., Author Summary The World Health Organization estimates that 50–100 million dengue infections occur annually. However, estimates based on cartographic modeling approaches suggest that up to 390 million dengue infections annually. Dengue has become an increasing public health concern in the Americas. A substantial number of cases in the Americas are reported in Brazil. There is a need for an updated evaluation of the economic impact of dengue in Brazil so as to allow decision/policy makers to make informed decisions on resource allocation and strategic planning. We estimated the economic burden of dengue in four regions. National cost estimates were based on the number of cases reported in Sistema de Informacao de Agravos de Notificacao (SINAN). Overall, 2,035 (91.5%) dengue cases were recruited to our study. More than 2 million suspected dengue cases and 569 deaths were reported in SINAN from September 2012 to August 2013. The annual national economic burden was US$ 164 million from the public payer perspective, but may be as high as US$ 447 million (adjusting for underreporting). From the societal perspective, the economic burden was US$ 468 million, but may be as high as US$ 1,212 million. The economic burden associated with dengue in Brazil is substantial.