 studies from India and also from Africa. Thank you, Suman. Thank you very much for inviting me to make this presentation, which is one cross-sectional analysis survey which was conducted in four countries, two in Asia, two in Africa, for KALAKOR program. KALAKOR is a UK-aid-sported initiative, which is primarily helping national governments to achieve control and to eliminate Kalaza. In Asia, we are working in three countries, Bangladesh, India and Nepal. And in eastern Africa, we are working in three countries, which are Ethiopia, Sudan, and South Sudan. In Asia, we are primarily providing support to achieve elimination target, which is to achieve a case load of less than 10,000 population at the district level in Nepal and sub-district level in India and Bangladesh. And in Africa, we are primarily supporting to enhance capacity for the real control in these three highest burdened real countries. KALAKOR was founded by four partners, which are listed here. MSF, DNDI, London School for Hygiene and Tropical Medicine, and Mod McDonald, who is the management agent for KALAKOR. And we are working with national control programs and with the local implementing partners. Local implementing partners are helping us to deliver a program there on the ground, which are both on the supply side and on the demand side. And primarily focusing to improve access to the quality case management in these six countries. Now, why we conducted this study? This study was conducted in 2016 in first, in early two quarters. And the prime objective of this study was to get a baseline for KALAKOR and also to provide us insights on where we need to focus our resources to achieve maximum output in terms of quality of care for real patients. And another kind of rational for this study was, since there is no recent evidences on VL, treatment seeking behavior, and also an economic burden. Though there are some studies which are conducted in Asia, and there is one study which has been done in Sudan, but these studies are not very recent. These studies are bit aged. And also because of the fact that now we have recent advancement, both in diagnostics and also in treatment for KALAZAR. So we thought of conducting this study using a standardized methodology. And in KALAZAR, we don't have much data with regard to treatment seeking, like we have in tuberculosis or in other diseases. So we thought of conducting this study in these four countries. And we designed an evaluation based on cross-sectional methodology, which we also hope to conduct at the end line. End line maybe in the last quarter of 2018. Kalakor end date is October 2018. So we hope to conduct at end line. And the patients were recruited from the health facilities, from which they have sought the treatment. And the sample size calculation was done based on representativeness, statistical power, and operational feasibility. I would talk about these were quite challenging in terms of real patient. I will talk about challenges later. And what we basically aimed at to collect prospective information as much as we can. We placed investigators at these treatment centers to collect information using exit interview questionnaire on these areas. But the challenge was to get as many as number in the prospective mode. So we did go to collect some retrospective information, but the maximum length which we restricted ourselves was to three months. Now quickly going over to the results. This is first slide is on how respondents say with regard to real knowledge. And this knowledge is primarily, I would like to make a point here, this is before they reached health center for the treatment. So this is the prior tools they are seeking of the health treatment. And this slide shows they are with regard to prevention-related indicators and also treatment-related indicators. So you can see that overall knowledge is quite low. And also excess, we asked the respondent, have they ever heard any message with regard to VL? This was also came out to be quite low in Bangladesh. It's just 0.7%, though in India it was around 33%. Now on the treatment seeking. So as I said earlier, these are the number of the facilities from where we interviewed patient, which ranged from 8 in Ethiopia to 17 in Bangladesh. Though in Bangladesh the number is high, but majority of the patients came from the single center SKKRC, which treats around 80% of the cases. And the number of the respondent which we interviewed was around 800 with the range of 136 in Bangladesh to around 297 in India. Most of our respondents were male with highest number in Ethiopia, which was around 97%. Because of the fact that in Ethiopia, most of the respondents were male migrant workers in Ethiopia. And their age group was in the range of 20 to 30. But in Sudan it was mainly the younger age group which we caught there in our sample. Now what they have said that the immediate number of providers which they have visited was around four or three. But for example in India, one of the patients said that that patient had visited eight providers before that patient received the diagnosis. And this is the place where usually patient has to receive the diagnosis. If you can see that most of these patients have received the diagnosis at the public health center. But place of the treatment was quite different. So only 36% and 37% in Asia, they received the treatment at the site of the diagnosis. It could be because of the fact that in Asia we are, especially in India, we are using a hub and spoke kind of a model where diagnosis can be available at every PSC but treatment is only available at the limited center. And in Bangladesh, most of the patients were referred to SKKRC for the treatment. Now this is a kind of, we try to plot four cutoff point in the treatment seeking behavior. On the left extreme is the onset of the symptom. And the first point is when patients sought any kind of help outside the home. So usually what we can see that in India and Bangladesh, the patient has went out of home. And usually these points were pharmacist or informal providers. But it takes quite a bit long to get confirmed diagnosis. So on median was 40 approximately in India. And in Bangladesh it was around 38. And once they received the diagnosis, confirmed diagnosis, the treatment was more or less given in four and six days. In Ethiopia, though there was a bit kind of more time was taken to approach the services, but later on the time was not much long. In terms of economic burden, we try to calculate the cost, which mean cost, which has been incurred by the patient. So there are three rows, which I would like to go one by one. The uppermost cost is the cost incurred on the medical treatment and diagnosis. Second line is mainly non-medical cost, such as food, transport, and all other associated non-medical cost with regard to treatment. And the third row is overall economic cost, which includes loss of wages, all the opportunity cost of the patient, and of attendance. Now, as you can see that the cost of medical cost, though in Bangladesh it's around $123. But in other three countries it's around $60 to $70. But when it comes to non-medical cost, it increases quite significantly in Sudan. Most of the respondent had spent the money on food, especially on transport, which is quite kind of important for us to know. And also when we see the economic cost, overall, it quite increases six-fold and five-fold. And what we try to analyze on how many percent of households they spent, 20% of their annual household expenditure on one single real episode. So you can see that 16% they said that they have spent in India in one single episode. And similarly, though in other, it's less. But when it comes to overall economic cost, the percentage increases from 16 to 51 in India. So and what it has led to? It has led to most of the patients, they have to use their savings. But in India and Bangladesh, approximately 68% to 75% of the patient, they had to take loan from somewhere to pay for the loss with saving card. And also nearly one fourth of the patient in Bangladesh and one third and with 50% of the patient in Sudan, they had to sell their livestock or crops to manage that economic loss which they had for VL. So what are the cost drivers? So these are, we try to categorize cost drivers in three categories. In Asia, it's more of treatment and on diagnostic, it's free, but even then, most of the patient are expanding their money on treatment and diagnostic before they receive the confirmed diagnosis free and also free treatment. So that's quite interesting. And in Africa, the most of the cost drivers are food transport. Well, so these are the findings, but I would also like to talk about the challenges. As we know that VL is a focal disease. For example, when I was talking about Bangladesh, we had one center reporting about 80% of the cases. So it was a big challenge for us to have a kind of evaluation design and get samples equally reprinted from all the places. And also the numbers of the VL is also coming down. The major challenge would be in the end line because by the end line, we will do like in Bangladesh, number of cases are reducing quite significantly. And also some of the other factors we wanted to include, but we were not able to include like PKDL, HIV co-infection and other groups. We tried to standardize the methodology across four different countries, which are quite different in terms of their treatment policies and in terms of their overall national policies on VL. But we tried to standardize the methodology and also having indicators and calculation for economic burden was also quite challenging. And also this is another big challenge which I would like to mention here, that we only assessed. We only asked patient those who reached the health care services. So still we haven't, you know, we have missed. We may have missed the patients, those who are not reaching the health care services. Conclusion, VL does result in substantial economic loss. And loss, though treatment and diagnosis are given free in the health care services, in the health care system, but the financial risk because of other things are quite huge. And we need to think about providing a broader social protection to cover non-medical costs. So that could be quite important. And also we will work on some of the areas which we have identified to address these issues. I would like to acknowledge all my team members, those who contributed to this. A many task team of Kalako, which comprised of WHO Geneva, London School for Health and Tropical Medicine and our partners in all the four countries and our funder, UK. Thank you very much. Thank you, Vikas. I'd like to invite one or two questions, please. OK. So maybe there'll be one question. I just wanted to state, you know, there's two very obvious, the data he has shown on the time from symptoms to time to seeking treatment. If you look at the papers done about 10 years back, has similar results. So we have not been able to make much progress, I think, hardly any progress on that side. Because that's the crucial thing, is how do you make the patients seek treatment early? Because that has implications not only from a patient's perspective, also from the control program perspective. And secondly is that would also affect the economic cost. So my perception is, you see, we should not look at disease in isolation. We should look at the patient. And the patient is suffering from fever. And if you look at the proportion of patients with fever, a long fever of more than a week, 10 days, having kalazar, it would be, even in endemic areas, it is only about 10%. So we need to also take the whole, the 90% of the causes of fever also need to be taken into consideration. And you need to have a strategy where you'll be able to diagnose maximum number of pathologies. Because that's what the patient wants. He's not only interested in one disease. So this is something which we have to realize, and we need to think accordingly. I think, Subhan, you made a very important point. And we have also realized that why a patient is not promptly reaching to the health care center. It could be because of the various factor. Though we are addressing most of the awareness raising issues at the company level, but I think our messaging priority need to be focused. We need to talk about the treatment availability and also the syndromic approach on fever. Okay, so now, yeah. So there's a question from our online audience. Do you have any percentage of patients who actually receive financial benefits from government of Bihar? I won't be able to say the percentage right now, but what all things which we have analyzed and what we know, it's almost all patients are receiving. There could be some delay because now that payments are made through bank account, we have money cut, readily transferred to the banks. But yes, all the patients which I have interacted, they have received it. Okay, thank you very much. I think we'll have to close the session now. I'd like to thank all the speakers for the excellent presentation and the audience for the discussion.