High-Risk Trachoma Patients Less Likely to Pay for Treatment

May Decrease Government’s Ability to Fight Disease Progression

Tanzanians who are at the greatest risk of contracting trachoma, a chronic infection that causes blindness, are the least willing to pay for azithromycin treatment, according to researchers from the Johns Hopkins Bloomberg School of Public Health. The researchers conclude that governments should continue to make antibiotics available free of charge in trachoma-control programs. The article, “Household willingness to pay for azithromycin treatment for trachoma control,” will appear in the February 2003 issue of Bulletin, the magazine of the World Health Organization (WHO).

Kevin D. Frick, PhD, lead author of the study and associate professor of health policy and management in the School of Public Health, said, “Many individuals with symptoms suggested they would forgo treatment rather than pay for future antibiotic treatment. Therefore, if a government ever wanted to charge for the antibiotic in order to recover some of its costs, that plan might limit access for those who need the drug most and make it more difficult to eliminate the infection and the later complications, which include blindness.”

In the Kongwa district of central Tanzania, close to 60 percent of preschool children have trachoma and eight percent of adults over the age of 55 have trichiasis, a complication of repeated trachoma infections in which the eyelashes turn in upon themselves and cause abrasions on the cornea. Previous estimates have suggested that at any one time, 5 to 7 million people are blinded as a result of trachoma infections and 300 to 500 million more have the disease.

Researchers looked at 394 households in six villages of central Tanzania to associate the willingness to pay for azithromycin treatments with measures of socioeconomic status, risk factors for active trachoma, and perceived benefit of initial treatment. After receiving an initial treatment, 38 percent of those studied indicated that they would not be willing to pay for future treatments, although they would be willing to receive the treatments.

Researchers found that patients were more willing to pay for treatments when they could use household items, such as the tin in their roofs, as payment. In addition, households that perceived a benefit from the initial treatment were also willing to pay a higher amount for future antibiotics. Since owning cattle was both an indicator of wealth and a risk factor for trachoma, the researchers expected to find that people with cattle would be more likely to pay a higher amount for treatment. Instead they found they were willing to pay less. In addition, members of a household headed by a female not in a polygamous marriage, which indicates a lower socioeconomic status, was associated with a lower willingness to pay for treatment.

The WHO recommends a four-pronged approach for controlling trachoma called SAFE, which includes surgery, antibiotic treatments, face washing and health education, and environmental changes. Traditionally, tetracycline was used to treat the disease, but it is more burdensome to administer than other trachoma-treatment antibiotics. Azithromycin treatments are in the form of a pill or liquid dosage and can be taken as little as once per year.

Frick explained, “Successful control efforts require resources much greater than the cost of antibiotics. The delivery of antibiotics and the provision of the other aspects of the SAFE plan are expensive and it takes years for trachoma-control efforts to succeed. Learning who is willing to use personal resources as payment for follow-up treatment will help target the promotion of mass treatment programs for communities with endemic trachoma and thus maximize the response to the programs used to combat the infection.”

Additional authors were Sheila West and Beatriz Munoz, with the Johns Hopkins School of Medicine, and Harran A. Mkocha, with the Kongwa Trachoma Project in the United Republic of Tanzania. Matthew Lynch also co-authored the report.

Research was supported by grants from the Edna McConnell Clark Foundation and the International Trachoma Initiative. Pfizer, Inc. provided the Zithromax® that was used in the mass treatment program in the villages.