Revenue-driven in TB control--three cases in China.

One quarter of all TB cases occur in China, which, during the past 20 years has moved from a planned economy to a socialist market economy. In the health sector, an important proportion of the financing originates from user payment. TB control is not an exception and different programmatic models are in place. This study examines, using a case study approach, three different TB programmes, one supposed to provide free service, one subsidized service and one with full cost recovery. The aim was to better understand the driving forces for programme performance in terms of case detection, case management and patient payments. The study found for all models that control and case management approaches were, to some extent, adapted to generate maximum income to the providers. The drive for income led to fewer cases detected, administration of unnecessary procedures and drugs, and a higher than necessary cost to the patients. The latter possibly leading to exclusion of poor people from the services. If user charges are to stay, TB control programmes need to be designed to take advantage of the financial incentives to improve performance. The referral system needs to be restructured, not to provide disincentives for good practices.