An important epidemiological challenge for TB control in China is inadequate and late case detection . Understanding the factors that underpin delays in accessing TB services as well as delays in receiving prompt diagnosis and treatment is central to effective control . In this review, results of qualitative and quantitative analyses indicate that patient and diagnostic delays in TB diagnosis and care are mediated by a constellation of individual patient factors and health systems factors. As noted by Glanz et al., individual-level factors include demographics, knowledge, attitudes, behaviors, beliefs, perceived barriers, skills, gender, level of education, socioeconomic status and so on. Health systems factors include factors that operate within the health system that promote or hinder patients’ access and treatment . These include health system financing, health services delivery, resources and support systems, governance community inputs and human resources . At the individual level, results in the review showed that socio-demographic, mostly economic factors (lack of health insurance), rural residence, gender, seeing a TMC provider, educational level and low knowledge of TB are important determinants of patient delay.
The review showed that rural residence was an important determinant of patient delay in seeking and receiving care for TB. It is estimated that a third of TB suspects in China’s rural settings do not seek care after three weeks of persistent cough, and lower-income individuals are less likely to seek care for TB than higher-income individuals . Programs such as DOTS have proven successful in detecting and treating TB infection in China. However, concerns have been raised regarding the impact of such programs on the most vulnerable members of the populations, particularly the rural poor . In spite of the progress made by TB control programs, “the prevalence of active PTB in rural China, particularly the Western region, has in fact, increased” . Thus, greater focus on equitable distribution of TB-related resources and improved targeting of vulnerable rural populations is of central importance in the control of TB .
The review highlighted the practice of seeing a TMC provider as a cultural factor that underpins patient delays in seeking and receiving TB diagnosis and treatment. Many Chinese TB patients would have visited a TCM provider for their ill-health before seeking care at a formal TB health facility . One potential problem with seeking a traditional provider prior to attending a TB diagnosis and treatment facility is that it results in diagnostic and treatment delays . TCM providers have been shown to recommend Western antibiotics along with traditional healing methods, and generally do not question the effectiveness of Western medicine . Training them to identify early signs and symptoms and prompt referral of suspected cases to TB diagnosis and treatment centers is important. Their propensity to refer cases can be enhanced through an incentive mechanism that rewards them per positive TB case referred to a TB diagnosis and treatment center.
Another cultural aspect of TB diagnosis and treatment delay is the stigma that is attached to the disease, which drives individuals to hide their condition from others, thus hindering them from accessing available diagnosis and treatment services. One study which focused on public awareness about TB concluded that approximately 72% of respondents held some stigmatizing attitudes towards the disease. Increasing public knowledge and awareness of TB as a disease that can be diagnosed and successfully treated if detected early is important for TB control efforts in the country . Available evidence shows that interventions to reduce the TB stigma can be effective if designed to empower individuals with TB to resist stigmatizing judgments, while working to change norms about the disease .
Finally, health system financing was been shown to be an important health systems determinant of patient delay in seeking TB care. Although the number of people living below the poverty line in China continues to decline as the economy grows, gross inequity, particularly in the financing of health, remains, as there is still significant difference in terms of socioeconomic development between the Western and Eastern part of China. The innovative, pre-market economy Chinese health system of the 1950s to 1970s has since disintegrated . In an effort to control the TB epidemic, China has instituted a policy of free diagnosis and anti-TB drug treatment. In spite of this policy, all income groups still have to pay out-of-pocket for the services that are included in a free TB care package, such as a liver protection drug, CT scan exams, and so on, and costs are usually high . This is largely a result of the marketization of healthcare services as a result of economic reform launched in the 1980s in China . Access to medication can be lower and initial access to care may be delayed as a result of financial barriers [70, 71].
To counter the impact of financial barriers on TB care, many TB programs began to incorporate material and financial performance-based incentives for patients, and occasionally, providers in the 1990s. Evaluation studies of these incentive programs show that they can be effective in reducing diagnostic and treatment barriers and delays . Supported with funding from the World Bank, China experimented with an incentive-based approach in the 1990s called the Convergence Management System under the National TB program of the MOHC, whereby the program provided free or subsidized TB diagnosis (including sputum tests and chest X-rays) and treatment (first line anti-TB drugs) to infectious TB patients diagnosed and treated in County TB Dispensaries (CTD) . Under the Convergence Management System a bonus was paid to doctors in general hospitals that referred suspected TB patients to the CTD. Unfortunately, the full potential of this approach could not be reached because the referral bonus was only available to hospital doctors, and not village doctors. A rethink of the contribution of the incentive-based approach to TB management in China is warranted given the enormity of the TB burden in the country.
Similarly, China’s once successful Cooperative Medical System (CMS) in the rural areas collapsed in the early 1980s leaving the majority of rural dwellers uninsured. The situation did not improve until 2003 when the Chinese government started to re-establish New Rural Cooperative Medical Scheme (NRCMS) . The NRCMS covered over 90% of the rural population in China by 2011. In addition, the government also started to establish Urban Resident Basic Health Insurance (URBMI) covering children and urban residents not covered by Urban Employee Basic Health Insurance . However, both URBMI and NRCMS do not offer a generous service package (for example, only inpatient services are covered in most places of China, and they do not provide a high level of financial protection since both deductible and co-payments are high). In spite of this increasing coverage, out-of-pocket medical care costs remain a significant expense, particularly for rural residents. More recently, the free treatment policy has been extended to smear negative patients  and the government also provides transportation and nutrition subsidies for low income TB patients . These notwithstanding, patients still make significant amounts of out-of-pocket payments for the total cost of their treatment. Approximately 40% of healthcare costs are paid out-of-pocket by individuals as a result of deductibles and other expenses. Overall, cost continues to present a major barrier against diagnosis and treatment of TB in the rural communities of China with significant implications for inequity in TB control in the country. Considering the high burden of TB in the country, it is unlikely that the government will be able to provide completely free treatment for all TB cases in the foreseeable future, given the huge financial consequences and the reductions in international donor support for TB control efforts .
This review did not identify randomized controlled trials, which was expected since experiments that expose people of diverse backgrounds to TB in order to assess how they seek diagnosis and treatment would be unethical. Consequently, the review included mostly cross-sectional, one case-control and one cohort study. These studies have a number of inherent limitations that have the potential to introduce bias in the results of this review. For example, the included cross-sectional studies had low comparability and were fraught with numerous confounders. Although the studies controlled for these confounders using logistic regressions, their residual effect might have introduced some degree of bias to the review.
Most of the available studies had different definitions of patient and diagnostic delays, as well as multiple classification of socio-demographic variables, including age, income, education and type of health facility consulted by TB patients. This limits comparability of the studies, and makes pooled analyses of results difficult. The meta-analysis was restricted to studies that adopted the definition of patient delay proposed by the Office of TB Control in the MOHC (that is, a time interval of more than two weeks between the onset of TB symptoms and the patient’s first presentation to a health facility). We acknowledge the limitation in accurately determining actual onset of TB symptoms by patients, given the generally low knowledge of TB among the public .
Implications for policy and practice
As findings of this review show, rural residence is an important determinant of delay in seeking diagnosis by TB patients in China. At a time when there is global emphasis on the use of community health workers for health promotion and disease prevention at the community level, the need to resurrect the use of health workers at village and township levels to fight TB in rural China cannot be over-emphasized . They are well-placed to provide individualized and community-based education and promotion to dispel ignorance and to challenge TB stigma. They can also be effective in referring suspected cases to appropriate sources of diagnosis and treatment, and can serve as key liaisons between communities and the national TB control program.
To address the negative impact of high out-of-pocket payments, it is important to integrate TB control efforts into the overall health system, especially health insurance schemes. The National TB Program (NTP) in China has recently started to work with the Ministry of Civil Affairs that is responsible for medical financing assistance for the poor to ensure that TB patients, particularly MDR-TB patients, can be diagnosed in a timely fashion and treated successfully, regardless of their ability to pay . It is also important for the China CDC to develop measures to ensure that clinical guidelines for TB diagnosis and case management are effectively implemented not only in TB dispensaries and TB-designated hospitals, but also in the general hospitals of China. Training of health workers in effective implementation of established guidelines for TB diagnosis and treatment should also be seen as an important component of the arsenal available for addressing the high burden of TB in China, as is the development of monitoring and evaluation systems to assess the performance of these service providers.