Health Policy and Planning Advance Access originally published online on May 25, 2006
Health Policy and Planning 2006 21(4):265-274; doi:10.1093/heapol/czl014
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Health service providers' perceptions of barriers to tuberculosis care in Russia
1Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK 2Centre for Health Management, Tanaka Business School, Imperial College London, London, UK 3Department of Microbiology and Infection, King's College, London, UK and 4Sociological Centre, Samara University, Samara, Russia
Correspondence: Dr Richard Coker, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK. Tel: +44 (0) 207 927 2926; Fax: +44 (0) 207 612 7812; E-mail: Richard.Coker{at}lshtm.ac.uk
The Russian Federation has witnessed a marked rise in rates of tuberculosis (TB) over the past decade. Public health TB control institutions remain broadly modelled along pre-1990 lines despite substantial programmes of investment and advocacy in implementing the World Health Organization's ‘Directly Observed Treatment—short course’ (DOTS) strategy. In 2002, we undertook a qualitative study to explore health care providers’ perceptions of existing barriers to access to TB services in Samara Oblast in Russia. Six focus group discussions were conducted with physicians and nurses from facilities in urban and rural areas. Data were analyzed using a framework approach for applied policy research. Barriers to access to care were identified in interconnected areas: barriers associated with the health care system, care process barriers, barriers related to wider contextual issues, and barriers associated with patients’ personal characteristics and behaviour. In the health care system, insufficient funding was identified as an underlying problem resulting in a decrease in screening coverage, low salaries, staff shortages, irregularities in drug supplies and outdated infrastructure. Suboptimal collaboration with general health services and social services limits opportunities for care and social support to patients. Worsening socioeconomic conditions were seen both as a cause of TB and a major obstacle to access to care. Behavioural characteristics were identified as an important barrier to effective care and treatment, and health staff favoured compulsory treatment for ‘noncompliant’ patients and involvement of the police in defaulter tracing. TB was profoundly associated with stigma and this resulted in delays in accessing care and barriers to ensuring treatment success.
Key Words: tuberculosis, health services accessibility, health care providers, focus groups, Russia