Conservation action based on threatened species capture taxonomic and phylogenetic richness in breeding and wintering populations of Central Asian birds.

Although phylogenetic diversity has been suggested to be relevant from a conservation point of view, its role is still limited in applied nature conservation. Recently, the practice of investing conservation resources based on threatened species was identified as a reason for the slow integration of phylogenetic diversity in nature conservation planning. One of the main arguments is based on the observation that threatened species are not evenly distributed over the phylogenetic tree. However this argument seems to dismiss the fact that conservation action is a spatially explicit process, and even if threatened species are not evenly distributed over the phylogenetic tree, the occurrence of threatened species could still indicate areas with above average phylogenetic diversity and consequently could protect phylogenetic diversity. Here we aim to study the selection of important bird areas in Central Asia, which were nominated largely based on the presence of threatened bird species. We show that although threatened species occurring in Central Asia do not capture phylogenetically more distinct species than expected by chance, the current spatially explicit conservation approach of selecting important bird areas covers above average taxonomic and phylogenetic diversity of breeding and wintering birds. We conclude that the spatially explicit processes of conservation actions need to be considered in the current discussion of whether new prioritization methods are needed to complement conservation action based on threatened species.

Factors determining household expenditure for tuberculosis and coping strategies in Tajikistan.

OBJECTIVE: To investigate factors influencing expenditure levels and the use of potentially detrimental coping strategies among tuberculosis (TB) patients. For the purpose of the present study, potentially detrimental coping strategies included borrowing money and selling assets. METHOD: Questionnaire survey with an initial and a follow-up interview of each adult new pulmonary TB case registered over a period of 4 months, conducted in 12 districts with DOTS in Tajikistan, one of the poorest countries in the world. RESULTS: Patients and their households faced mean expenditures of US$ 396 related to a TB episode. In multivariate mixed-effect regression models, the main determinants of out-of-pocket payments-either over the whole course of the disease or after enrolment in DOTS treatment-were 'complimentary treatment' besides the anti-TB drugs, duration of hospitalization and treatment delay. Complimentary treatment mainly consisted of vitamins and rehydrating infusions. Sex showed no association with expenditure. To cope with the costs of illness, two-thirds of patients employed a potentially detrimental coping strategy. TB patients raised on average US$ 23 through loans with interest, US$ 57 through loans without interest and US$ 102 through selling assets. CONCLUSION: The catastrophic out-of-pocket payments faced by TB patients are correlated with receiving complimentary treatment, delay to treatment and duration of hospitalisation. The widespread use of potentially detrimental coping strategies illustrates that TB constitutes a substantial risk of impoverishment. More parsimonious use of complimentary treatment and hospitalisation could reduce illness-related costs for patients and should be carefully considered.

Illness costs to households are a key barrier to access diagnostic and treatment services for tuberculosis in Tajikistan.

BACKGROUND: Tuberculosis (TB) control is based on early detection and complete treatment of infectious cases. Consequently, it is important that TB suspects and patients can readily access medical care. This qualitative study investigated determinants of access to DOTS services as identified by patients, health providers and community members in four districts in Tajikistan. FINDINGS: Focus group discussions were conducted in order to investigate access to TB services. A conceptual framework for access to care guided the analysis. Thirteen focus group discussions involving a total of 97 informants were conducted. Content analysis of discussions and a rating to quantify the relative importance of discussed factors were carried out. The conceptual framework identifies five main components of access to which factors can be assigned: availability, adequacy, acceptability, accessibility and affordability.Financial factors were considered the most important determinants of access to diagnosis and treatment of tuberculosis. Expenditure for drugs and consultations, for transport, and for special foods as well as lost income were identified as major barriers to treatment. Stigma, doubts about curability and low perceived quality of care were not seen to be significant determinants of access to care for tuberculosis. Community members were well aware of symptoms of tuberculosis and of medical services. These findings were consistent between different respondent groups (community members, patients and providers). They were also highly consistent between the open discussion and the confidential rating. CONCLUSIONS: Illness-costs to households were identified as the main barrier to tuberculosis diagnosis and treatment. To improve access and ultimately adherence to tuberculosis treatment, effective mitigation strategies, e.g. changes in case management, food contributions or financial stimuli, need to be explored and implemented.

Patient's site of first access to health system influences length of delay for tuberculosis treatment in Tajikistan.

BACKGROUND: Tajikistan has the highest incidence rate of tuberculosis (TB) in Central Asia. Its health system still bears many features from Soviet times and is under-funded. Affordability is a major barrier to health care. Little is known about health care seeking of TB patients in post-Soviet countries and their delay until the start of TB therapy. The low estimated case detection rate in Tajikistan suggests major problems with access to care and consequently long delays are likely. METHODS: The study investigated extent and determinants of patient and health system delays for TB. A questionnaire was administered to a cohort of TB patients in twelve study districts representing a wide range of conditions found in Tajikistan. Common patterns of health care seeking were analysed. Cox proportional hazards models using eight predictor variables, including characteristics of health services delivery, were built to identify determinants of patient and health system delays. RESULTS: Two-hundred-and-four TB patients were interviewed. A common pattern in treatment-seeking was visiting a specialised TB facility at some stage. Typical delays until start of TB therapy were moderate and did not confirm the expectation of long delays. Median patient, health system and total delays to TB treatment were 21.5, 16 and 52 days, respectively. None of the investigated predictors was significantly associated with patient delay. The type of facility, where patients made their first contact with the health system, was the main determinant of health system delay (p < 0.00005). We show for the first time that patients who had fallen ill and first presented to health care in Russia had the longest delays. Those who first presented to peripheral primary care facilities also had relatively long delays. CONCLUSIONS: While overall delays were moderate, further improvement is needed for different subgroups. An international referral system between Russia and Tajikistan to reduce delays of Tajik migrants who develop active TB in Russia is urgently needed and would benefit both countries. Within Tajikistan, diagnostic pathways for patients in the periphery should be shortened. To achieve this, strengthening of sputum smear examination possibly including collection of sputa at peripheral primary care facilities may be needed.

Household costs of illness during different phases of tuberculosis treatment in Central Asia: a patient survey in Tajikistan.

BACKGROUND: Illness-related costs incurred by patients constitute a severe economic burden for households especially in low-income countries. High household costs of illness lead to impoverishment; they impair affordability and equitable access to health care and consequently hamper tuberculosis (TB) control. So far, no study has investigated patient costs of TB in the former Soviet Union. METHODS: All adult new pulmonary TB cases enrolled into the DOTS program in 12 study districts during the study period were enrolled. Medical and non-medical expenditure as well as loss of income were quantified in two interviews covering separate time periods. Costs of different items were summed up to calculate total costs. For missing values, multiple imputation was applied. RESULTS: A cohort of 204 patients under DOTS, 114 men and 90 women, participated in the questionnaire survey. Total illness costs of a TB episode averaged $1053 (c. $4900 purchasing power parity, PPP), of which $292, $338 and $422 were encountered before the start of treatment, during intensive phase and in continuation phase, respectively. Costs per month were highest before the start of treatment ($145) and during intensive phase ($153) and lower during continuation phase ($95). These differences were highly significant (paired t-test, p < 0.0005 for both comparisons). CONCLUSIONS: The illness-related costs of an episode of TB exceed the per capita GDP of $1600 PPP about two-and-a-half times. Hence, these costs are catastrophic for concerned households and suggest a high risk for impoverishment. Costs are not equally spread over time, but peak in early stages of treatment, exacerbating the problem of affordability. Mitigation strategies are needed in order to control TB in Tajikistan and may include social support to the patients as well as changes in the management of TB cases. These mitigation strategies should be timed early in treatment when the cost burden is highest.

Simplifying paediatric immunization with a fully liquid DTP-HepB-Hib combination vaccine: evidence from a comparative time-motion study in India.

An observational time-motion study investigated logistic, programmatic and safety-related advantages and limits in the delivery of a fully liquid DTP-HepB-Hib combination vaccine versus a lyophilized combination vaccine requiring reconstitution. The study was conducted in 2006, observing 312 child vaccinations in a tertiary hospital setting in Kolkata, India. The time for vaccination was on average 46s (35.12%) lower with the fully liquid vaccine (p<0.05). In addition, the fully liquid combination was easier and potentially safer to handle and as well tolerated as the lyophilized formulation. Fully liquid combination vaccines have the potential to simplify immunization schedules, contribute to better resource management and improve efficiency of immunization programs.

Access to medicines and out of pocket payments for primary care: evidence from family medicine users in rural Tajikistan.

BACKGROUND: In Tajikistan it is estimated that out of pocket payments constitute two-thirds of all health spending with high proportions of these contributions through informal payments. As a consequence, access to basic care is a major concern particularly among the most needy and vulnerable groups. This article evaluates accessibility of prescription medicines and patient expenditures for primary care services in two rural districts of Tajikistan. METHODS: 901 patients aged 18 years or above who had accessed primary care facilities were interviewed, using a questionnaire based on questions regarding patient's experience of visiting the health facility. To group respondents by socio-economic status, an asset index was created using principal component analysis of the information included in the questionnaires. RESULTS: 76.7% of patients were prescribed a medicine during the visits and more than 83% of them managed to obtain it. Patients spent on average US$ 9.3 on medicines, with wide variation among socio-economic groups. Around 45% of patients paid the Family Doctor. Additionally, over 41% of patients in the highest socioeconomic quintile were referred to a specialist, while only 29% of the poorest 40%. CONCLUSION: This survey showed that there are financial barriers potentially inactivating utilization of basic services. These barriers can only be reduced by mobilizing more public resources to fund the health sector, providing incentives for family doctors to stop requiring payments from patients, and increasing the availability of prescription drugs in PHC facilities.