Data collection

The de-identified dataset of DRTB patients registered between 2015 and 2018 in ZJ, JL and NX was retrieved from the TBIMS of Chinese Center for Disease Control and Prevention (China CDC). While previously only MDR/XDR-TB patients were registered as a specialized category in TBIMS, in recent years patients resistant to at least one type of first-line anti-TB drug are gradually registered and included in standardized anti-DRTB treatment according to their DST results. The dataset contained three basic sets of information: (1) demographic information of DRTB patients including age, gender, ethnicity, residence, etc.; (2) diagnosis and treatment information, including all drug-resistant tests (DST) taken, the results, and the status of any anti-DRTB treatment; and (3) sputum and culture tests taken during the treatment period.

The medical records of all DRTB patients registered in 2018 in the six sample prefectures who had completed inpatient treatment were retrieved from designated hospital. In total 106 medical records were examined: 24 in ZJ, 58 in JL, and 22 in NX. These records were examined by clinical experts according to the following constraints: (1) the usage of molecular DST; (2) the rationality of treatment regimen, defined as whether drugs in the prescription were selected based on DST results using the guidelines developed by China CDC; and (3) the treatment status and the negative rate of culture test after 6-months’ treatment. Similar examination was also conducted at the baseline survey in 2015, but the sample size (< 50) was too small for the comparison before and after intervention.

The DRTB patient survey was conducted in the six sample prefectures in August 2019. The questionnaire collected information on patient demographic and socio-economic status, treatment experiences, treatment costs, and OOP expenditures during the first six months of treatment. Eligible participants include DRTB patients that were registered between February 1, 2017 and February 1, 2019 in the six study sites who had completed six months of treatment. Patients over 15 years old were sampled successively following a reverse chronological order of the registration date. The expected sample for each prefecture was 70, based on the number of patient cases in the study period. If the total number of eligible patients was less than 70, then all patients were sampled. Face-to-face interviews were conducted by trained investigators using a structured survey questionnaire loaded in a tablet PC. Oral consent was obtained before the interviews.

Semi-structured in-depth interviews were conducted to understand the how the designed interventions were implemented during the project period. In-depth interviews were conducted with informants from provincial and prefectural level health commission (n = 9), CDC (n = 9), health insurance office (n = 9) and the insurance division of designated hospital of the sample prefectures (n = 9).

Focus group discussions were conducted to understand patient treatment experiences and causes of financial burden. FGDs were held with physicians in designated hospitals (n = 7) and DRTB patients (n = 6), and each focus group had 4–6 participants. Eligible DRTB patients were those who had completed 6 months of treatment. Patients were selected based on their gender, socio-economic status, insurance type, and distance from downtown areas.

All interviews and FGDs were conducted in a private room by experienced researchers. Oral consent was obtained before tape-recording. On average, each interview lasted 30–45 min and the FGD was around one hour.