Economic transition which took place in China over the last three decades, has led to a rapid marketization of the health care sector. Today inequity in health and poverty resulting from major illness has become a serious problem in rural areas of China. Medical Financial Assistance (MFA) is a health assistance scheme that helps rural poor people cope with major illness and alleviate their financial burden from major illness, which will definitely play a significant role in the process of rebuilding Chinese new rural health system. It mainly provides assistance to cover medical expenditure for inpatient services or the treatment of major illnesses, with joint funding from the central and local government. The purpose of this paper is to review the design, funding, implementation and to explore the preliminary effects of four counties' MFA in Hubei and Sichuan province of China.We used an analytical framework built around the main objective of any social assistance scheme. The framework contains six 'targeting' procedural 'steps' which may explain why a specific group does not receive the assistance it ought to receive. More specifically, we explored to what extent the targeting, a key component of social assistance programs, is successful, based on the qualitative and quantitative data collected from four representative counties in central and western China.In the study sites, the budget of MFA ranged from 0.8 million Yuan to 1.646 million Yuan in each county and the budget per eligible person ranged from 32.67 Yuan to 149.09 Yuan. The preliminary effects of MFA were quite modest because of the scarcity of funds dedicated to the scheme. The coverage rate of MFA ranged from 17.8% to 24.1% among the four counties. MFA in the four counties used several ways to ration a restricted budget and provided only limited assistance. Substantial problems remained in terms of eligibility and identification of the beneficiaries, utilization and management of funds.MFA needs to be improved further although it evidences the concern of the government for the poor rural people with major illness. Some ideas on how to improve MFA are put forward for future policy making. For a long time, the international research community has paid relatively little attention to the specific needs of the poorest in low-and middle income countries. Recently however, there has been growing recognition of the miserable life of the chronic poor and of the need to better understand the causes of their exclusion from basic social rights . This inThe health sector is no exception to this rule. In a majority of countries nowadays, households have to contribute with out-of-pocket payments to access health care services . This fiRecent Chinese developments are in line with the above mentioned trend. In the last three decades, while the Chinese economic success story has caught deservedly the attention of the whole world, health inequity has become an increasingly serious challenge for China. Both the media and academic researchers have frequently reported the inequity issue of health and health care between rural and urban areas, regions, and different economic population groups. Within either urban or rural area, poorer health statues can be observed for low-income population groups. A study on 73, 497 individuals conducted in Hunan province reported that the low-income population suffered more health problems using the indicator of disease concentration index . DiffereThe Chinese government has started to implement a number of policy interventions related to the promotion of equity. Among those policies, the establishment of the New Cooperative Medical System (NCMS) and Medical Financial Assistance (MFA), are essential for improving equity in health in rural China.The "Decision to further strengthen rural health work"  establisThe purpose of this paper is to use a sequential framework developed by Meessen and Criel to explore the effectiveness of MFA in reaching the target group at different stages of program initiation and implementation . MeessenIn the first section, the study sites and methods of this study are presented. Next, the analytical framework is introduced. In the results section, we use the analytical framework to shed light on the way MFA targeting unfolds in several consecutive steps. Similarities and differences in design, implementation and management of MFA in the four counties are pointed out. After a short section on the preliminary impact of MFA in the four counties, we conclude with a discussion of the main findings and ways forward.This study is part of POVILL, a comparative European Union funded research project on the relation between poverty and illness in three Asian countries. In China, the survey rests on four counties: Xiaochang, Hongan, Langzhong and Fushun. The former two are located in Hubei province of central China, the latter in Sichuan province of southwest China. Xiaochang, Hongan and Langzhong are designated as poor counties by the government. This is not the case for Fushun. Table Quantitative data were drawn from the so called Rapid Household Survey (RHS) and official documents of the four counties. In the RHS, 12, 131 households were selected through multistage cluster sampling. First, three townships were chosen randomly from each county; then, 10 villages were selected randomly from each township; finally, about 100 households were selected randomly from each village. RHS included modules on household assets, demographics, health status of household members, utilization of health services, medical expenditures, reimbursement of NCMS and MFA assistance.Qualitative data were collected through semi-structured interviews conducted by researchers with officials of county health bureaus, county civil affairs bureaus, county hospitals, township health centers and civil affairs offices. In Xiaochang and Hongan, qualitative interviews were conducted in July 2007; in Fushun and Langzhong, interviews were conducted in April 2007. Data and information concerned 2006 though. In each bureau or hospital, we interviewed about two or three key informants. In total, we interviewed about 10 to 15 informants in each county. The interviews focused on MFA policy and aspects, such as the design, implementation, performance and problems. The key information on MFA was collected from county civil affairs bureaus and township civil affairs offices that are in charge of management and implementation of MFA. Supplemental information was gathered from county health bureaus, county hospitals and township health centers, which may be related to MFA indirectly.Targeting is the policy option of concentrating the benefits of an intervention on a pre-identified specific group. Social assistance programs obviously target the poorest. To our knowledge, there is today no clear academic guidance on how to analyze social assistance programs. A large body of literature focuses on the outcomes of the targeting process, but most of these studies are rather silent on implementation issues. In a review of international experiences, Coady, Grosh and Hoddinott noted that the quality of implementation matters tremendously to the targeting outcome and that there was thus an obvious need for further work on implementation. "Program managers need to be able to know more about the details of what was done elsewhere, why the choices were made, how they worked out, and what circumstances affected the outcomes" .Meessen and Criel have put forward an analytical framework built around the main objective of a social health assistance intervention: to have a significant impact for a well identified group of beneficiaries. The framework analyses the intervention in terms of possibilities for the program to have limited impact. The program could fail to reach the target group or bring insufficient assistance to the beneficiaries. They identify six 'targeting' procedural 'steps' which may explain why a specific group does not receive the assistance it ought to receive: (1) the formulation of the intervention; (2) the definition (in measurable terms) of the intended group of benefit; (3) informing the stakeholders, including the target group; (4) the identification of individuals meeting the eligibility criteria; (5) the entitlement; (6) the utilization of the service subsided by the program".The first step is the programme formulation gathering all the activities related to the initiation of the intervention. Policy makers should clearly formulate their ambition. The target group should be specified and the aim of the intervention should be clarified. In addition, the targeting method and benefit package should be at least broadly defined according to the objectives. Step 2 is the definition of eligibility. In this step, a variety of experts often shows the way forward. It is important to acknowledge that the setting of the eligibility criteria is closely related to the budget available for the intervention. In step 3, the stakeholders are informed: this refers to the different actions taken to inform the different stakeholders about what the programme has to offer. The information about the programme should not only reach actors directly involved, but also all the actors regularly dealing with the target beneficiaries through other programs. Step 4 is the identification of the individuals eligible for assistance. This step amounts to screening a population to identify individuals meeting the eligibility criteria set in the second step. Step 5 is the entitlement, i.e. the action of granting the entitlement for assistance to the sub-population identified in the fourth step. The key issue here is to establish the new status of the individual as a right they can vindicate. Ideally, the entitlement must quickly follow the identification. The entitlement must be clear on the benefit package it gives access to. The last step is the delivery of assistance to the subpopulation entitled in Step 5. The key issue here is to provide assistance that will bring a real benefit for the assisted person. In each of these steps, something can go wrong for potential beneficiaries.Starting in October 2002, a series of policies were promulgated by key ministries of the central government, like the Ministries of Health (MoH), Civil Affairs (MoCA) and Finance (MoF), sometimes jointly. Policy measures announced were respectively 'the decision to further strengthen rural health work' , 'ProposMFA is a highly decentralized program, with local governments having discretion over both policy design and implementation. Variations across localities can occur, for example to take into account local circumstances. After the promulgation of the series of decrees on MFA by the central government, the four counties in our study swiftly launched the program. Fushun launched MFA in 2004, and the other three counties started in 2005. The four counties had set up their respective MFA scheme in line with the central policy decrees, adjusting it where necessary to the local situation. The workload was assigned to different bureaus and sections.The county civil affairs bureau is in charge of the daily operation of MFA, which includes tasks like formulating specific regulation, checking the application of beneficiaries, distributing funds and other management issues of MFA. The township civil affairs offices, which are under the supervision of the county civil affairs bureaus, deal with publicity, identification of beneficiaries and households to be visited; the village civil affairs cadre or village cadre is expected to advertise the scheme, assess the eligibility status of households and identify the beneficiaries.The county financial bureau is in charge of the collection and supervision of funds. MFA funds are allocated by upper level financial departments to lower level financial departments. Funds are for instance transferred from the central to the provincial level. Regardless of the source, funding is under the supervision of the county financial bureaus through a special bank account.The county health bureau is responsible for the provision of medical services in a network of hospitals in the four counties. The county health bureau supervises all the hospitals.No single special department is in charge of supervising these three bureaus , but all the departments are supervised by the related department from a higher level. Moreover, the work of the county civil affairs bureau is regularly checked by the county financial bureau. Also, meetings gathering officials from the three departments are organized on a regular basis to discuss MFA related affairs.The providers of medical services are more rigorously defined in Xiaochang and Hongan, while in Fushun and Langzhong every hospital is acceptable for MFA. In Xiaochang, no coordination with NCMS existed at the time of research because NCMS had not yet been implemented in this county in 2006. In the other three counties, the county civil affairs bureau pays the NCMS premium for the households eligible for MFA, and the county civil affairs bureau and health bureaus are responsible for the coordination between MFA and NCMS.MFA has to combine at least two sets of eligibility, according to economic criteria ('who is poor') and medical criteria (what is a major illness) respectively.As for the economic criteria, the central government has not provided a specific definition of the 'poor for MFA' so far. In the implementation of MFA, the local governments of the four counties capitalized on other social assistance schemes' regulations to define the 'poor for MFA'. In the sites under study, the main categories of households that are eligible for MFA are those households who were registered in Wubao(Five Guarantee Program), Dibao(Minimum Income Guarantee Scheme), Tekun(Assistance for the Extremely Poor Households) and Youfu, see table In Xiaochang, besides these four categories, other households with a family member suffering from major illness or generally leading a hard life can also be included in MFA if their situation is verified by the county government. In Fushun, the criteria are slightly different. Besides Wubao and Tekun, people who sank into poverty due to major illness can also be included in MFA.There is no national definition of 'major illness' in China at present - and rightly so, given the large variation existing within the country. In Xiaochang and Hongan, the illness categories included in MFA are circumscribed. In Fushun county, major illness is identified as 'illness with a major impact on daily life', such as cancer, nephropathy etc.. In Langzhong county, major illness refers to illness with inpatient expenditure over 5000 Yuan Table . We mustAt first sight, criteria of the MFA seem rather straightforward. However, as discussed under step 4, due to budget constraints, there can be discrepancies between the theory and the practice.Once the county civil affairs bureau, county health bureau and county finance bureau have agreed on the regulation documents, the latter are sent to township government or lower level departments directly involved in the implementation of MFA. Besides, copies of regulation documents are also sent to indirect stakeholders such as the Office of the County People's Congress, the Office of the County People's Political Consultative Committee etc.. Although informing the relevant departments is very important, obviously the key stakeholders to contact are poor households . The MFA policy is publicized by the county civil affairs bureaus mainly through websites, banners, scrolls, leaflets, bulletins, New Year pictures, mobile loudspeakers, broadcasting etc. The methods of publicity may vary a little among the four counties according to their local situation. The township civil affairs offices are in charge of publicizing and informing the poor rural households of the MFA scheme. Then the targeted households may apply to the county civil affairs bureaus for assistance or else they can be directed by their neighbor or village officer to the township civil affairs offices. According to official documents, MFA was heavily advertised to poor households in all counties. But, RHS findings show that the awareness rate of MFA was nevertheless rather low in the four counties Table . Only abThis step involves screening an actual population to identify individuals meeting the eligibility criteria set in Step 2. Under step 2, we have reported restrictive but rather clear criteria. However, meeting these criteria may not be sufficient: more often than not, quotas are applied at township level.In counties where NCMS is in place, the economic criteria are applied ex ante: they are used to identify households of which the NCMS premium will be paid by MFA. Medical criteria are used ex post: they are assessed once a household claims reimbursement for a specific episode of illness. In two of the three counties with NCMS, priority is also given to households who have already received some reimbursement from the NCMS.When the poor who meet the abovementioned economic criteria receive inpatient treatment or outpatient treatment for major illness as defined by the local government, they are allowed to submit a formal application to the village civil affairs cadre or village cadre for MFA assistance. After getting the application for MFA, the village civil affairs cadre or village cadre makes a household assessment of poverty and diseases by paying a visit to the applicants' homes and their neighbors, checking their certificate of household characteristics, receipt of hospitalization, certificate of discharge from the hospital, NCMS reimbursement certificate. Village cadre discussion takes place as well. Next, the applicants are ranked at township level according to the extent of poverty and medical expenditure. In Fushun and Langzhong, households who receive NCMS reimbursement get priority for MFA assistance over other households. According to the quota of assistance as allocated by the county civil affairs bureau, beneficiaries are identified. After verification by the civil affairs office, certificates are awarded as evidence of MFA qualification. The number of assisted beneficiaries depends on the budget. The approval frequency of assistance is different for the 4 counties: once a month in Xiaochang, once every 2 months in Hongan, no more than 1 month after the application in Fushun, and in Langzhong once during the first half year and once every three months during the last half year.In MFA regulation, county civil affairs bureaus bear the main financial risk; it comes as no surprise then that their strategy is to only allocate the funds after having received the money from the respective administrative levels. Consequently the identification process tends to be relatively conservative, especially in the first half year, to prevent an MFA fiscal deficit.In a nutshell, step 4 of the MFA scheme includes both verification (by checking whether the household meets the eligibility criteria) and rationing of the available budget (by ranking households eligible for assistance).An entitlement can be assessed on two dimensions: the assistance it gives access to and its certainty. As for MFA, we have seen that in three counties, MFA finances the NCMS premium of eligible households. More specifically, those people who meet the economic criterion are entitled to free enrolment to NCMS and will benefit from basic benefit package of NCMS when they are sick and seeking care. This is a secured entitlement. Yet, the benefit package is rather shallow, as the NCMS schemes are practicing rules  that severely restrict the proportion of health care expenditure those households get reimbursed. Those people meeting both economic criteria and medical criteria will benefit from additional support (direct cash assist after treatment) by MFA.As shown in table Practically speaking, the entitlement takes the format of a certificate issued by the county civil affairs bureau. As already mentioned, it can take some time to receive this certificate. The applicants can get cash assistance through the MFA certificate from the civil affairs bureau, the township civil affairs office or a bank identified by the civil affairs bureau.If applicants want to seek health care at other hospitals than the designated hospitals (i.e. portability of the entitlement), they must get a grant from the county civil affairs bureau and the county health bureau before treatment, otherwise, MFA will not assist them. However, in most cases, the designated hospitals for MFA are the same as the designated hospitals for NCMS, which include township health centers, and county-level hospitals. This may be for fund rationing and management convenience considerations.MFA benefits are provided in two ways. One way is direct cash assistance from the funds after utilization of hospital services. In Xiaochang, the only county where there was no NCMS in 2006, this is the only way to receive assistance. In the other three counties with NCMS on the other hand, MFA provides its benefits in two ways. First, it pays the NCMS yearly premium on behalf of the households meeting the household characteristics criteria , the county civil affairs bureau cannot enroll all the poor households  in MFA. Hence, as we mentioned in step 2, the county civil affairs bureau used the records of four other social assistance schemes  to define 'the MFA poor'. The four social assistance categories of households are identified by the county civil affairs bureau by assessing their economic status. The households included in these four categories amount to the most destitute among the poor households identified by the county government using the 'National poverty line'. The county civil affairs bureau enrolled all the households that appeared on the name lists of Wubao, Dibao, Tekun and Youfu in the MFA scheme. According to the official documents of the four counties, the coverage rate of MFA in 2006 ranged from 17.8% to 24.1%. The coverage rate in Langzhong county was higher than the rates in other counties (see table In table The MFA budget of Xiaochang and Hongan (Hubei province) is lower than the MFA budget of Fushun and Langzhong (Sichuan province), but the benefit amount per actual beneficiary in Xiaochang and Hongan is higher than in Fushun and Langzhong. The number of people enrolled in NCMS with help of MFA is relatively similar in Hongan, Fushun and Langzhong, but the total expenditure for paying the NCMS participation fee is substantially higher in Hongan than in Fushun and Langzhong due to the higher NCMS participation fee per person in Hongan. In Hongan, a substantial share of the MFA budget is in fact allocated to the NCMS premium.It is interesting to compare this information from the routine information system with the data collected from households. According to RHS, the coverage rate of the households is extremely low (6.9%). The difference between the respective coverage rates in table In the RHS data, only 20 households reported to have received direct cash assistance from the MFA, which accounted for more than half of the 38 households covered by MFA in the sample. So the rate of MFA utilization among households aware of their MFA status is rather high; this is encouraging. Among the 20 households, the minimum benefit was 50 Yuan, the maximum benefit was 3000 Yuan and the median was 1100 Yuan. Among the 18 households who did not get assistance, 15 households had members who got major illness and also incurred medical expenditure. Given that the RHS was conducted in early 2007 and the application for assistance did take some time, these household may have been in the process of application at the time.Our interviews with local officials offered another source of information on the preliminary effect and performance of MFA. Officials in the four counties all claimed that MFA is a really good scheme, as it evidences government concern for the poor with major illness and is helpful in relieving poverty due to major illness. However, they admitted that MFA could not fully solve the poverty trap caused by major illness, due to the limited funds available. For example, medical expenditure for some major illnesses such as leukemia and uremia was huge, but the financial relief provided by MFA was often woefully inadequate. When the poor are unable to prepay for hospitalization, MFA is incapable of paying either. Besides, for those who need pre-assistance, the MFA scheme is ineffective due to the post-assistance mode, which only provides assistance after the poor person has paid her/his bills in the hospital. In the officials' view, a better MFA scheme thus mainly depends on better MFA policy making and a higher budget.Progress towards universal coverage will require specific schemes to help the poorest to avail the services they need. The purpose of this paper was mainly to review the design and implementation of MFA in four counties in Hubei and Sichuan province, using the analytical framework developed by Meessen and Criel . The papStep 1: While formulated at national level, the MFA policy allows decentralized governments quite some leeway to operationalize the strategy. Nevertheless, one can observe great homogeneity in the four countries in terms of implementation. This is particularly striking for the roles of the different bureaus and the modesty of the budgets allocated to the policy. This limited financial commitment is an obvious first reason why MFA does not reach all the poor rural households struggling with their medical bill. It can also be interpreted as an indication that local governments do not consider medical assistance to the poorest households a top priority.Step 2: We observe also great homogeneity in the four counties in terms of eligibility criteria: they are invariably very restrictive. Poverty hinges on an administrative definition, i.e. being a Wubao, Dibao, Tekun or Youfu household. The thresholds of these social assistance schemes are very low, hence, many poor households are excluded from MFA. In other words, a lot of the proclaimed targeted benefiaries of the MFA policy are already lost at the eligibility definition step. We have seen that MFA decentralized operators were aware of the rather restrictive character of these eligibility criteria. They often tried to use the medical expenditure criteria to be more inclusive. However, this flexibility could also be used to ration access to the MFA.The main stated purpose of MFA is to help rural poor people cope with major illness. We have seen that MFA endorses a view that major illness is a problem handled at least at hospital level, with a bias towards inpatient care. This is another reason why the MFA may miss its target. There has been some debate lately in the Chinese literature on the appropriate definition of major illness -21. Lu sStep 3: Official documents we reviewed suggested that the county governments had made some effort to inform the stakeholders, especially the poor that were targeted by MFA. However, RHS has revealed that only a small fraction of the poor households were actually aware of MFA. The semi-structured interviews we conducted allowed us to explain at least to some extent this puzzling observation. Some officials said that the local governments were reluctant to advertise MFA due to limited funds. They were afraid that the budget of MFA would not suffice if too many poor people applied for assistance. Hence, many poor people did not know that MFA was intended to help them cope with major illness. Publicizing MFA or not was really a dilemma for local governments. Informing stakeholders is a vital step where many poor households can end up being excluded due to a lack of information: those who have no access to the media and other sources of information will not hear about the program; it is then impossible for them to take the required subsequent steps, e.g. submit an application.Step 4: Identification processes in the four counties were fairly similar. MFA is an ex post assistance scheme: the identification is based on certificates and documents proving that the household deserves to be partly reimbursed for its expenditure. We have seen that the village cadres play a key role in the identification: they make the household assessment of poverty and diseases and have a discussion to identify the poor households. We have not collected evidence on possible favoritism, an issue sometimes reported with community-based targeting [argeting .Step 5: We have seen that the decision by the village civil affairs cadre or the village cadre does not guarantee that the program will actually assist the household. Due to the extremely limited funds, MFA managers ration the assistance. In Sichuan, for instance, poor households which received NCMS reimbursement get precedence for MFA assistance over other poor households. Households claiming assistance are also ranked. Other citizens can also contest the eligibility of someone (lists of people requesting reimbursement are made public). The requirement to provide many documents, the uncertainty on the final assistance and the obligation to rapidly claim the reimbursement are certainly possible causes for losing some of the target group. Having said this, a strength of MFA is that it could become a rights-based policy. We have seen that at least for Wubao and Tekun households, MFA has become an extension of their welfare status.Step 6: We have seen that MFA could provide two types of benefits: a premium for enrolment in NCMS and reimbursement of medical bills. The first option has some leverage effect: being a member of the NCMS scheme does indeed allow the household to get more reimbursement for their hospital expenditure. Yet, this will occur only if the household uses the inpatient services. The problem, identified also by our key informants in Sichuan, is that MFA does not remove the barriers to hospital utilization at all. The scheme focuses on reducing ex post the financial burden of hospital utilization: it is still the household itself that has to mobilize resources to reach the hospital, e.g. transport, cash to pay medical bills. By design, it is more a scheme trying to protect consumption than to enhance good health. The second objective would indeed require providing an entitlement guaranteeing assistance ex ante and ex post, substantial enough for convincing households to go to the hospital. If no assistance is provided ex ante, paying NCMS premiums through MFA could in fact be regressive, as the pooled resources will benefit only those able to afford hospital utilization. As correctly identified by officials in Sichuan counties, the MFA loses many poor because of its ex post mode of assistance. This situation amounts to so-called 'negative cross-subsidization'. From a systems perspective, community health insurance may result in poorer groups contributing to their health care costs to a greater extent than richer groups who are able to access public services, and thus may be inequitable with respect to payment [ payment . Jacobs  payment . Annear  payment .With respect to the preliminary impact of MFA in these counties, the general picture was assistance to a disappointingly low number of poor patients, although we observed some variation across the four counties. According to the semi-structured interviews, the main reason for this phenomenon was limited funding. China is a quite decentralized system in terms of government funding. Most of the responsibility for financing MFA rests upon local governments, particularly the counties. This has contributed greatly to the scarcity or even absence of social protection programs in rural areas .The results show that at the time of research MFA did not reach its objectives. The main cause was the scarcity of resources dedicated to the program. Different mechanisms were and probably still are in place to ration the assistance. In the end, too few households benefited from the assistance and the assistance was probably too meager to make a real difference.This paper provided also an opportunity to assess - in rural China - the validity of the framework developed by Meessen & Criel for the health equity fund experience in Cambodia. This question has relevance beyond the Chinese context: the question of how to assist the poorest in their utilization of health services is indeed a universal one. In a previous paper, Meessen et al. had also partly used this framework to compare the user fees exemption policy in Uganda with health equity funds in Cambodia. Although the two policies took place in very different countries and displayed many differences in implementation, the basic idea or rationale of this framework proved useful to analyze health assistance schemes . HoweverChina is a country experiencing very rapid economic development and policies are adapted continuously. In June 2009, the Ministry of Civil Affairs issued the 'Suggestion on further improving Medical Financial Assistance'  to improIn August 2009, we visited Langzhong again to follow up the implementation of MFA. According to the interview with managers of this scheme, some problems described in this paper had been addressed in Langzhong, but some key issues still existed, such as the very limited funds, the low coverage rate and no united service platform of MFA and NCMS.The real future of the MFA scheme lies probably in comprehensively addressing all the barriers the poor encounter when trying to access a basic package of curative services. Time will tell whether social health assistance really takes off in rural China.The authors declare that they have no competing interests.XM, JZ, BM, YY and XR contributed to the design of this study. JZ, MB, KD and XT performed data analysis. All authors contributed to the draft writing of the manuscript. MB and KD also contributed to polishing this manuscript. All authors have read and approved the final manuscript.


As the popularity of e-therapies grows, so too has the body of literature supporting their effectiveness. However, these interventions are often plagued by high attrition rates and varying levels of user adherence. Understanding the role of adherence may be crucial to understanding how program usage influences the effectiveness of e-therapy interventions.The aim of this study was to systematically review the e-therapy literature to (1) describe the methods used to assess adherence and (2) evaluate the association of adherence with outcome of these interventions.A systematic review of e-therapy interventions was conducted across disease states and behavioral targets. Data were collected on adherence measures, outcomes, and analyses exploring the relationship between adherence measures and outcomes.Of 69 studies that reported an adherence measure, only 33 (48%) examined the relationship between adherence and outcomes. The number of logins was the most commonly reported measure of adherence, followed by the number of modules completed. The heterogeneity of adherence and outcome measures limited analysis. However, logins appeared to be the measure of adherence most consistently related to outcomes in physical health interventions, while module completion was found to be most related to outcomes in psychological health interventions.There is large variation in the reporting of adherence and the association of adherence with outcomes. A lack of agreement about how best to measure adherence is likely to contribute to the variation in findings. Physical and psychological outcomes seem influenced by different types of adherence. A composite measure encompassing time online, activity completion, and active engagements with the intervention may be the best measure of adherence. Further research is required to establish a consensus for measuring adherence and to understand the role of adherence in influencing outcomes. The past two decades have seen a shift from traditional face-to-face consultations to technology-driven interventions or e-therapies. Recent reviews have shown that e-therapies are both effective -3 and grA potential difficulty in evaluating these programs is adherence (see ). LittleThe eHealth equivalent of failing to persist with therapy is treatment dropout. Treatment dropout refers to when a user prematurely stops using the intervention. Some of these users may remain in the trial, completing the trial assessments, while others may choose to leave the trial. Those who choose to leave the trial early are said to have discontinued and are reflected in trial attrition rates. Such attrition can affect the ability of results to be generalized ,11 and iWhile an appreciation of persistence is important in evaluating e-therapy, an understanding of adherence to the program content, such as the completion of program modules or online activities, may be more so. As the field of e-therapy has been growing, so has the interest in potentially modifiable user factors that may influence adherence. Clearly, program content evolves from empirically supported research, but only recently have the exploration and manipulation of program factors become foci. Program usability and feasibility testing is increasingly common. Recent findings have indicated that greater use of computer relational skills, such as the use of empathy and social dialogue in the computer program, leads to increased program usage . Many trE-therapy trials have an advantage over traditional trials when measuring persistence and adherence, in that more objective measures of intervention usage are readily available to researchers. Objective measures of persistence include metrics such as the number of times the participant accesses the program, and adherence measures include the time spent online, number of completed activities, and patterns of usage. Subjective measures, such as estimated time spent online, reporting on the completion of behaviorally based homework activities, and use of skills, can also be incorporated. Despite the relative ease of capturing these data in online interventions, few studies report these statistics. Merely reporting on adherence and dropout provides limited insight about the impact of adherence on program outcomes or the translation of program behaviors into daily life. Even fewer studies examine the role of adherence on outcomes. The few that do, by publishing only significant results, may result in publication bias.Recent studies have begun to address this through the exploration of the relationship between program exposure and outcomes -30. AlthTo inform this development, we conducted a systematic review of the literature evaluating adherence in e-therapies. Within the context of this review, adherence is defined as the degree to which the user followed the program as it was designed. The two aims were (1) to review the methods used to assess adherence and (2) to evaluate the association between adherence measures and outcome.A systematic database search was used to identify articles relevant to the aims of the review. Articles published up to and including April 2010, as indexed by Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials databases, were included. Broad keyword search terms were used, favoring sensitivity over specificity, given the relative youth of the field. Search terms used were the keywords “Internet” OR “web” combined with “therapy” OR “self-help” OR “intervention.” Following this initial search strategy, we identified 8300 articles . When reporting results, the study needed to report 1 or more adherence measures (defined as a measure of program usage by the participant) as well as the outcome of the intervention.Articles that were not written in the English Language were excluded. Design characteristics that led to exclusion were the participant concurrently receiving a psychotherapeutic intervention in addition to the intervention being studied, or that the program involved synchronous communication as part of the program . These studies were excluded to remove the potentially confounding nature of instantaneous feedback, extrinsic motivation, social desirability, and uncontrolled social contact. Studies with telephone contact were included if the calls were reported to be scripted, described as nontherapeutic in nature, and for the purpose of tracking participants.Additionally, further studies were excluded because the individual completing the program was not the individual displaying the target behavior , the program was not delivered over the Internet , or the program was delivered at a specific location or time , therefore requiring the participant’s presence online at that time or place.Key article characteristics were recorded using a data extraction template designed for this review. Key data captured for analysis consisted of variables that would allow the articles to be reviewed and factors thought to be important in adherence, based on a review of the literature.These factors consisted of study sample size; the study design, including the nature of the control and intervention; the behavior or state that was the target of the intervention; and a description of the intervention, its therapeutic underpinnings, its intervention style, and its requirements from users.In addition to the study characteristics, adherence data were captured. These consisted of a measure of the degree to which the individual engaged with the website as determined by program logins, engagement in online activities, time spent onsite, and the number of modules completed. Data were extracted for each adherence measure, including the type of measure and data reported relating to this. Any statistical analyses that examined the role of adherence in outcome were also recorded during data extraction.The data collected on adherence variables were aggregated and evaluated for strength of association with outcome. Due to the methodological challenges associated with Internet trials , it was difficult to use a widely used rating system. Given these challenges, an alternative rating system was developed, informed by the Scottish Intercollegiate Guidelines Network rating system . Based oWe initially found a total of 8300 studies by using the above combination of search terms. Once duplicates were removed, the articles were further limited to those that were published in an English-language, peer-reviewed journal (n = 1095). The remaining articles were systematically reviewed (by LD) to ensure they met the inclusion criteria. This resulted in a total of 74 articles describing 69 individual studies. The heterogeneity of adherence and outcome measures precluded a formal meta-analysis.Sample size varied significantly between the trials, ranging between 20 and 3176 (median 146), with many of the open-access trials having more participants . StructuMean study discontinuation rate was approximately 23% of all trial participants (range 0%–83%). Studies of physical and psychological target behaviors had similar attrition rates.Adherence data that were captured varied across studies. This included reporting the number of times the participant accessed or logged into the program, completed modules or activities, visits made to forums, posts made to the forum, and pages viewed and printed, as well as self-reported completion of activities away from the program or offline. Despite the commonality and functionality of being able to capture or measure participant logins across trials, only half (33/69) of the studies presented these adherence data in relation to outcome measures. See table 2 for a breakdown of ways in which adherence was measured in the included studies.Of the 69 studies included in the review, 33 (48%) analyzed the impact of 1 or more measure of adherence on outcome variables. Complete results of the review can be found in A total of 9 studies correlated logins as a measure of adherence to outcomes. Using the previously described rating system, logins were found to be positively associated with outcome in studies targeting food and vegetable consumption , physicaIn 6 studies, activities completed were correlated with outcomes. The number of self-reported activities completed  was found to correlate with outcomes in interventions that targeted cigarette smoking , weight Completed modules were the most commonly reported measure of adherence, and they correlated with outcomes in 16 studies. The number of modules completed was found to correlate with outcomes in interventions that targeted cigarette smoking ,46,47, dThe relationship between time spent online and outcomes was correlated in 4 studies. Time spent online was not correlated to outcomes in studies that targeted depression  and anxiThe number of pages opened was explored in 3 studies. The number of pages opened was negatively correlated to outcome in 1 study targeting depression  but posiThe relationship between website exposure and outcomes was explored in 3 studies. Website exposure and program usage was positively correlated with outcomes in interventions targeting smokeless tobacco , depress                        Understanding adherence to e-therapies is important in understanding how these therapies may benefit individuals who need intervention. The impact of adherence on outcome appears to vary. The review demonstrates that however it is measured, adherence is associated positively when reported with intervention outcomes targeting physical health. However, in the most commonly targeted outcome of e-therapy, depression, the number of logins, self-reported activities, time online, and pages opened showed no such association. Only 2 measures of adherence—the degree of completion of the modules within the program and a summative “website exposure” outcome—were associated with better depression outcomes.The association between the number of logins and outcomes in e-therapies targeting physical health is similar to the positive relationship observed between session attendance and outcome in physical rehabilitation -70 and tFor participants involved in trials targeting weight changes as an outcome -40, all The most common use of e-therapy is to intervene in depression and anxiety. However, measures of logins, self-reported activity completions, and time online were not associated with outcome—only evidence of actual module completion either on its own or in the composite “program exposure” measure appeared to be related to outcome. This suggests a more nuanced interpretation, in that a participant’s interaction with the module content leads to change, rather than improvement merely reflecting a greater propensity to adhere. This reflects the face-to-face literature, in that the structured psychotherapies, with module (task) completion and review, are generally more effective than supportive psychotherapy -74. The The definition of adherence and its consequent analysis also varied considerably across studies. Several studies categorized participants into adherent or not ,54,57,75The variation in measurement of adherence in online interventions makes it difficult to accurately determine the impact of adherence on outcome. Despite having several seemingly objective measures such as number of logins, time spent online, and activities completed, there are still difficulties in determining the “dose” a participant receives. Specifically, time spent online is likely to be influenced by factors such as processing speed, cognitive ability, reading aptitude, and familiarly with using computers, several of which are likely to be influenced by psychological health. Likewise, a person who is unfamiliar with using a computer may write out their activities, rather than engage in the functionality presented in the online environment. This needs to be explored further by studies that randomly assign participants to receive different doses of programs, such as that by Christensen et al , which eFrom this review, the mechanism of how adherence influences Internet treatment outcomes is unclear. Medical studies have shown that adherence is associated with better outcomes, regardless of whether patients received placebo or active interventions ,79. WithWe recognize that several key studies that were included in the original sample of 8300 were excluded as a result of selection criteria. Specifically, some trials that potentially would have met the review criteria were excluded before analysis as a result of database coding and indexing. While Cochrane-style systematic reviews have used rigorous data selection and extraction templates to select trials, the varied nature of the design and high attrition rate of e-therapies made it difficult to use such templates. Given this, the limits within the databases were used to ensure that the methodology of the review was as systematic and replicable as possible.As the studies contained within this review were heterogeneous in terms of the populations studied, nature of the interventions used, lengths of follow-up, and outcome measures, we summarized the findings by adherence measure only, rather than attempting a meta-analysis. This has limited the ability to combine and report the data beyond the format used. Similarly, the large number of small studies included in the review may have been underpowered for finding significant results.There are many difficulties in determining the role of adherence on outcomes in e-therapies. While objective data can be captured with relative ease, this may not truly reflect the user’s experience and dose. This is particularly pertinent when the user is required to complete activities such as homework exercises between online sessions, or when the user can print off material to review. In both of these scenarios, “objective measures” may underestimate the usage of the program. Similarly, user aspects such as processing speed, and familiarity with Web-based platforms and user interfaces are likely to influence the time spent online. Therefore, understanding the contributing factors of adherence is likely to be as important as understanding adherence per se.From the findings of this review, it appears that the number of logins is the measure of adherence best correlated with physical outcomes, while module completion correlated with psychological outcomes. This suggests that program persistence and adherence may be important for physical and psychological interventions in different ways. However, these results need to be considered with caution, given the limitations of this review and the potential biases in the data. We therefore recommend that this be explored in future studies where adherence is the focus. It may mean that an aggregated adherence measure such as program exposure could provide a more meaningful measure of adherence by incorporating logins, time spent online, and number of activities and modules completed. However, it is not always clear how such a composite measure was derived in the studies and how each factor contributes to such a score. Similarly, variations existed within composite measure across each trial, making the comparison difficult. Furthermore, the design of interventions could take this into account by maximizing the likelihood of a participant undertaking the behavior most likely to enhance outcomes. For instance, maximizing module completion for depression and anxiety interventions, even at the expense of number of logins, may be a good trade-off. Understanding the differential effects of different measures of adherence will be important in future content and platform development, as well as in evaluating applicability and health service issues.


This study compares ownership of health insurance among Ghanaian women with respect to wealth status and spatial location. We explore the overarching research question by employing geographic and proxy means targeting through interactive analysis of wealth status and spatial issues.The paper draws on the 2008 Ghana Demographic and Health Survey. Bivariate descriptive analysis coupled with binary logistic regression estimation technique was used to analyse the data.By wealth status, the likelihood of purchasing insurance was significantly higher among respondents from the middle, richer and richest households compared to the poorest (reference category) and these differences widened more profoundly in the Northern areas after interacting wealth with zone of residence. Among women at the bottom of household wealth (poorest and poorer), there were no statistically significant differences in insurance subscription in all the areas.The results underscore the relevance of geographic and proxy means targeting in identifying populations who may be need of special interventions as part of the efforts to increase enrolment as well as means of social protection against the vulnerable. In developing countries, the cost of health care financing is one of the biggest social challenges and out-of-pocket payments present significant drains on household spending patterns, making health insurance one of the best social interventions . HoweverIn Ghana, the legal framework for mandatory health insurance was promulgated in 2004 through an Act of Parliament, Act 650. While the establishment of an insurance scheme was in fulfilment of political promise made by the then ruling government during the 2000 general elections campaign, it was more of a response to a need to improve equity and access to health services in the face of increasing cost of health care.The WHO  concept In spite of the perceived successes of the health insurance scheme in Ghana, especially in terms of the number of subscribers, the major objective of achieving equity is believed to be failing, given the low enrolment of the poor -10. UnheA number of theoretical propositions have been expounded in the health insurance literature to explain decision-making processes towards subscriptions to health insurance in poor settings. Schneider  providedFrom spatial perspective, geographic targeting (GT)  providesThis paper contributes to the debate on purchasing of health insurance by examining the interactive effect of spatial location and household wealth status with special emphasis on women. Our focus on women is justified by the fact that this population, in the context of a developing nation, faces more health challenges than men, particularly as a result of reproductive health risks. By this, we do not seek to negate the health needs of men; just that women constitute a special population in our context. A recent study by Mensah et al.  providesThis study proceeds on the assumption that there are no significant interactive effects of household wealth status and spatial location on health insurance subscription among women in Ghana. Yet we are also mindful of the fact that there are other hypothetically pertinent dynamics which influence whether an individual would insure or remain uninsured. With respect to our dataset, the following variables: education, age, religion, partner’s education, autonomy  are conGhana is one of the first countries in sub-Saharan Africa to introduce a nation-wide health insurance scheme with an intention of replacing out-of-pocket payment health care regime. Prior to the state-sponsored implementation of health insurance in the country, the Catholic Church, through one of its hospitals in the Nkoranza District of the Brong-Ahafo Region, operated an insurance scheme, albeit limited to in-patient care. Fulfilling political campaign promise, the New Patriotic Party introduced an insurance scheme in 2004 following parliamentary approval. The scheme is financed with funds from a National Health Insurance (NHI) levy, collected from an additional 2.5% on value-added tax (VAT); a monthly deduction of 2.5% from each formal sector worker’s contribution to the Social Security and National Insurance Trust (SSNIT) pension fund; interests from investments made by the scheme; an annual premium contribution from all informal sector workers and those formal sector workers who are not covered by the SSNIT pension scheme; and a registration fee paid by all National Health Insurance Scheme (NHIS) subscribers to their respective District Mutual Health Insurance Schemes (DMHIS) with which they are enrolled in the scheme. While the premiums are preferred to be charged on ability to pay, the absence of reliable income data of several Ghanaians make this ideal impossible. Consequently, various district schemes charge flat rates for non-formal sector workers. By this arrangement, various district schemes charge premiums on the basis of economic potentials and activities prevailing at the district. Presently, the range of premiums is between GH¢7 and GH¢40 (approximately $3.5-$20.0). By June 2010, there were 145 schemes in operation across the country with a total registered membership of 15,555,815 (66.4%) of the population and 12,540,708 (53.6%) were active members of the scheme. Over 5,000 service providers were providing services on 95% of medical conditions. The scheme also has an exempt category of beneficiaries  .http://www.measuredhs.com).Data for this paper are derived from the female data file of the 2008 Ghana Demographic and Health Survey (GDHS) collected by the Ghana Statistical Service under the wave of surveys supported by ICF Macro International. The surveys are largely carried out in developing countries where continuous population monitoring through civil registrations are inadequate. The dataset is the most recent conducted by the Ghana Statistical Service in collaboration with the Ghana Health Service and MEASURE DHS four years after the introduction of the NHIS. In the 2008 edition, 412 clusters were generated based on updated enumeration areas from the 2000 Population and Housing Census. Of the 412 clusters, about 12,000 households were included and 4,916 eligible women between the ages 15 and 49 years were subsequently interviewed, with a response rate of 97%. After recoding the data to suit our needs, the sample for this paper reduced to 4,910. The MEASURE DHS gave us the permission to use this data set following an assessment of a concept note on the paper. The data is publicly available  and 0 = “No” (uninsured). Since the outcome variable was a dichotomous variable, we employed a discrete choice model to measure how the various independent variables correlated with the outcome. Specifically, the logit function was employed since it allows estimation on a mixture of continuous and categorical variables. The choice of region of residence and wealth status or quintile was based on differences in poverty scores across the various regions. For instance, the Ghana Shared Growth and Development Agenda (2010–2013) recognise that there are inequities in health care access in the country, with the south benefiting more than the north. In order to explore interaction of household wealth status with region of residence, we created a spatial variable by collapsing the ten regions into three: Western, Central, Greater Accra, and Volta as the Coastal area/zone; the Eastern, Ashanti, and Brong-Ahafo were categorised as the Central/Middle zone and the Northern, Upper East and Upper West defined as the Northern zone. Household wealth status in DHS dataset is an aggregation through factor analysis of a number of household belongings such as car, agricultural land, refrigerator, bicycle, materials used in constructing housing, television, radio, type of household cooking fuel and a host of others . The varAt the first and second levels of inferential analysis, factorial interaction was applied to spatial location and wealth status. This was intended to determine locational and wealth effects on insurance purchase alone and whether the effects remain when the two are interacted. The interaction of wealth with spatial zone helped us to identify differences within and among groups. Survey weights, which are typical of nationally representative surveys, were factored into both descriptive and inferential analyses. The weights help to offset the problems of over and under sampling associated with national surveys. That the individual respondents are nested in households also gave us the impetus to estimate robust standard errors to account for non-independence of individuals selected from the same household. Other independent constructs which influence decisions towards insurance purchases such as individual and partner’s education, religion, and age were used to adjust for the effects of spatial location and wealth index or status. All the analyses were conducted with STATA, 12th version .Table In Table Following the interaction of wealth with spatial zone, the significant differences still remain. The likelihood of purchasing insurance among women who are average and richer on the wealth gradient was about 150% - 300% higher. However, in Model 2 where we adjusted for the impacts of other socio-demographic variables, between group and within groups differences are illuminated better. In particular, the within group gap among the middle , richer  and richest  populations on one hand and that of the poorer  and the poorest (reference category) on the other in the Northern zone widens substantially. However, between group comparisons of the odds ratio for the poor and poorest in the Northern and Coastal zones, we find no significant differences, although the odds were higher in the Northern zone. Again, we also noticed higher likelihood of insurance subscription in the Northern areas compared to the Central areas. Figure Statistically significant impacts were also observed on age, personal education, and partner’s level of education. We also observed that partner’s education was more important predictor of health insurance subscription than individual’s own level of education. The likelihood of being a member of an insurance scheme was higher among women whose partners had obtained higher formal education  as compared to respondents who had attained higher education themselves . Differences in religious affiliation are noted but not significant. In terms of likelihood, the non-Christian groups  were less likely to own health insurance. Among the various factors that are proxy for autonomy , there are no statistical differences.In this paper, we examined the interactive effects of wealth status and spatial location  on ownership of health insurance among women. Data was drawn from the most recent women’s data file of Ghana Demographic and Health Survey (2008). Compared to most developing countries, Ghana is one of the few countries which have formally replaced out-of-pocket payment with insurance for health care delivery. Although the scheme has been described as one of the progressive schemes because of its indirect tax funding, it is, at the same time, considered regressive relative to informal sector contributions . The stuWe noticed that there are significant differences in subscription by spatial location of respondents. Somehow, the differences in subscription appear to favour the rich in some parts of the country more than others. The differences we noticed are more pronounced between the poor and the rich in the Northern area. In a recent review of health care financing equity in three African countries, Mills et al.  indicateIn some respects, the findings are consistent with those made by Schneider , who fouThe results again point to class dimension in insurance purchase. Women whose partners are better educated and wealthier were more likely to have purchased health insurance compared to the less educated and poorer Ghanaians. These findings are in agreement with other studies  on determinants of health insurance subscription. In a South African study, Kirigia et al. . The obsThe likelihood of health insurance subscription increases with aging and this could be an indication of risk perception. Kirigia et al.  found diThis study sought to investigate health insurance subscription among women in the reproductive ages, 15 – 49 years and we took a detour from previous studies to test the interactive effect of spatial location and wealth status on insurance subscription. At the interactive stage, significant differences within groups become clearer, observing that the poorest in the Northern zone were significantly less likely to have purchased insurance. This is notwithstanding the observation that women in the Northern zone were more likely to be insured than their counterparts in the Coastal and Central zones. The results underscore the relevance of geographic and proxy means targeting in identifying populations who may be in need of special interventions as part of the efforts to increase enrolment as well as means of social protection against the vulnerable.The author declares that they have no competing interest.AKK and JAA conceptualized the study. JAA analysed the data and drafted the manuscript. All authors participated in the interpretation of data. All authors gave final approval of the version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/13/221/prepub


Revised National Tuberculosis Control Programme (RNTCP), Delhi, India.To ascertain the number and sequence of providers visited by TB patients before availing treatment services from DOTS; to describe the duration between onset of symptoms to treatment.A cross sectional, qualitative study. Information was gathered through in-depth interviews of TB patients registered during the month of Oct, 2012 for availing TB treatment under the Revised National TB Control Programme from four tuberculosis diagnosis and treatment centers in Delhi.Out of the 114 patients who registered, 108 participated in the study. The study showed that informal providers and retail chemists were the first point of contact and source of clinical advice for two-third of the patients, while the rest sought medical care from qualified providers directly. Most patients sought medical care from more than two providers, before being diagnosed as TB. Female TB patients and patients with extra-pulmonary TB had long mean duration between onset of symptoms to initiation of treatment (6.3 months and 8.4 months respectively).The pathways followed by TB patients, illustrated in this study, provide valuable lessons on the importance of different types of providers  in the health system in a society like India and the delays in the diagnosis and treatment of tuberculosis. Globally, the burden of Tuberculosis (TB) is estimated to be highest in India. In 2010, out of the estimated global annual incidence of 8.8 million TB cases, nearly 2.2 million cases have been reported in India, of whom 0.9 million were infectious cases Evidence suggests that TB patients, particularly from low income groups or underserved areas take long and sometimes difficult pathways to reach health facilities that provide appropriate care Under the Revised National Tuberculosis Control Programme (RNTCP) of the Government of India, provisions have been made to provide access to diagnostic and treatment services in a decentralized manner through a network of ∼13,000 sputum smear microscopy centers and ∼650,000 of Directly Observed Treatment Short-course (DOTS) centers within the public health system In India, health care is predominantly sought from the private sector The study was undertaken in the city of Delhi, India, which has a population of 19 million (2011 census). An estimated 40% of Delhi’s population live in slums and local clusters. Most slum dwellers are migrants from other states of India. At 209 cases per 100,000 populations per annum, Delhi is ranked among the highest rate of TB notification in the country This study used qualitative research methods to gain an understanding of behavioral dynamics of the TB patients through describing and interpreting beliefs and practices while accessing medical care in a given community context. All consecutively registered TB patients in the month of October, 2010, who were availing treatment in these DOT centers, were invited to participate in the study. Patients who volunteered to participate were included in the study. Interview was conducted using a semi-structured questionnaire. Treatment records of all interviewed patients were verified from respective TB units for consistency.Interviews with the patients were conducted using a pre-tested, semi-structured questionnaire by a qualified medical professional trained in qualitative research studies. The questionnaire was in first developed in English, translated into Hindi and then then back translated into English to check for consistency. The responses from the individuals was recorded verbatim, translated into English and analyzed. Patients were requested to recall and narrate their experience of visiting different providers before they sought services from DOTS Centers . The questionnaire consisted of twenty five questions. Questions ranged from signs of early symptoms, sequence of providers visited, duration of medical care under each provider, time gap between successive providers, source of referral-if any, reasons for discontinuation of medical care, and reason to seek services from DOTS Centers. The private providers were categorized as qualified providers based on patients perception and description of the qualification of the doctor they visited , informal  providers , and chemists . In addition, Social, economic and demographic information  of the responding patients were collected.The study was reviewed and approved from the ethics committee of the University of Delhi-South Campus. Informed written consent was obtained from each participant. In order to ensure anonymity and non-disclosure of individual information, name of the patient was not sought in the questionnaire but compiled separately using serial numbers. Confidentiality clause was readout in the local language (Hindi) and explained. In case if the participant was aged less than 18 years, additional informed written consent was obtained from the parent or guardian accompanying the patient.Data was analyzed using Microsoft excel. Social and demographic profile of the patients was tabulated using simple descriptive statistics. Sequential movement (pathways) of patients seeking services from various providers was constructed using flow diagrams. Time taken from the on-set of symptoms to treatment at DOTS centers is been expressed in mean and standard deviation. Some of the relevant responses of the participants have been provided verbatim (after translation into English).Out of the 114 patients registered for treatment, 108 patients  agreed to participate in the study. The Profile of participants and the duration between onset of symptoms to treatment is given in st consultation, but others had visited qualified providers few more times (up to 6 times) before reaching a DOTS center.In this study, an attempt has been made to trace the pathways taken by TB patients while seeking medical care for their illness. The findings of the study indicate the range and sequence of providers, duration of medical care and thus explain the possible cause of delay in diagnosis and treatment of TB. If the pathways of treatment in a city with relatively higher mean income, literacy, and easy access to health facilities are of any indication, the situation in hinterland could be worrisome. This is particularly important as India is aiming to achieve ‘Universal Access’ for quality assured diagnosis and treatment under RNTCP First, it is inevitable but to recognize the importance of informal providers and chemists in the whole sequence of TB diagnosis and treatment cycle. This has been identified in other settings as well Second, success of TB control is possible only if the illness is diagnosed and treated in time, irrespective of the place of diagnosis or treatment. However, delays caused due to complex pathways followed by the TB patients before they reach a DOTS Center- as illustrated in this study, not only jeopardize their own wellbeing but also makes others in the community vulnerable for infection. Current Information Education and Communication and/or Behavior Change Communication strategies need to incorporate messages highlighting the need for patients to visit DOTS center, if they don’t get relief from symptoms even though they are visiting health care providers that are known to them.First, as in all observational studies, which elicit information on past experiences of the patients, this study may have recall bias of patients. But efforts were made to minimize errors in recall by asking them to relate with events, dates and co-relating it to available medical records. Second, the study was conducted in a few selected sites by recruiting patients registered during one month. Hence the study findings cannot be generalized to outside the study sites and the studied participants. However, the study finding does provide guidance on the potential pathways taken by patients. Third, the classification of providers into formal and informal was based on the perception and description of the patients, and we did not attempt to cross verify the correctness of this information by visiting the health care providers as this was not operationally feasible.The pathways followed by TB patients, illustrated in this study, shows the care seeking behavior from different types of providers  in the health system in a society like India and the duration between onset of symptoms to treatment of TB. There is a need to incorporate measures to address these issues in the TB control strategy of the country.