National TB programme inaccessible to patients

Rita Dutta - Mumbai

A health worker of the Delhi-based NGO- Sharan administering DOTS to a TB patient

Even as the country observed the World TB Day on March 24, 2003, the 10th anniversary of Tuberculosis being declared a global emergency by the World Health Organization (WHO), the Directly Observed Treatment, Shortcourse (DOTS) programme under Revised National Tuberculosis Control Programme (RNTCP) has become inaccessible to a large section of the population, according to experts.

According to a TB report card released by four NGOs on the World TB day, namely Massive Effort Campaign (Geneva), National Centre for Advocacy Studies (Pune), Result International (New York) and Sahasee (Delhi), which is an analysis of the third quarter report of DOTs in 2002, the detection and cure rate of the programme is less than thirty per cent for more than half of the population of the country. The analysis reveals that for the states of Andhra Pradesh, Bihar, Haryana, Karnataka, Jharkhand, Madhya Pradesh, Orissa and Punjab the cure and detection rate is less than 30 per cent. This states constitute 56 per cent of the population of the country. The study shows that cure rate is above 60 per cent for Delhi, Himachel Pradesh, Manipur and Rajasthan (which only constitutes eight per cent of the population) and it is between thirty and sixty per cent for Maharashtra, Tamil Nadu, West Bengal, Gujarat and Kerala (which form 31 per cent of the population).

Experts attribute this to the failure in roping in private practitioners (PPs) under DOTS, inconvenience caused to patients due to the timings of DOTs centres, failure to adapt the programme to the needs of children, bureaucratic hassles and reluctance to pick up patients.

While the government is investing Rs 6 crore and borrowing as much as Rs 100 crore from the World Bank for DOTS, experts urge that the government needs to assess the accessibility of the programme before its planned expansion of DOTS coverage from the current 450 million people to 850 million people in the next 18 months. The government has set a target of treating at least 3,500 (70 per cent) of the new TB patients on DOTS each day, and cure 2,975 out of those (85 per cent) in order to reduce the death rate by half by the year 2005.

Experts point that the government needs to monitor the service delivery, as patients need to be identified and 70 per cent of them need to be picked up. Says Dr Kanchan Mukherjee, lecturer, health services studies, Tata Institute Social Sciences, “The old National Tuberculosis Control Program (NTCP) was more active than RNTCP as it had community health workers making door-to-door visits and identifying patients with TB. DOTS is a passive programme as it depends more on Information Communication and Education (ICE). Community health workers educate people about TB, along with a host of other diseases. Ideally, it should be a combination of ICE and picking up of patients.”

According to Dr Bobby John, director, Massive Effort India, which is the Indian representative of Massive Effort Campaign, “Coverage is not equivalent to accessibility. The government might boast of a good coverage by setting up innumerable DOTS centres, but what it needs to see is how many people are aware of their nearest DOTS centre and how many are turning up at the centres. It is only during the World TB day that the government advertises about the programme.”

The list of complaints against the DOTS centres are endless. Says Dr Nalini Krishnan, executive member, Resource group for Education and Advocacy of Community Health (REACH), a Chennai-based NGO which is working with Chennai Corporation hospitals and private practitioners as a DOTS-provider, “The DOTS centres are not patient-friendly because of inconvenience in timing. The centres open only after 11 in the morning and doctors walk in even later. Patients are expected to skip work thrice a week to get treatment. This results in high drop-outs. We have been trying to change the government timings to early morning, but that has been of no consequence.”

Similar complaints are echoed everywhere. Admits Dr G Ambe, member secretary, Mumbai District Tuberculosis Control Society, “Yes, we have heard of the inconvenience caused to patients because of clinics refusing to conduct microscopy test after 11 am. They were doing it because of work over load. We have already given them orders to the stretch their timings.”

Experts say that bureaucratic hassle is another bottleneck, the heck of conforming to a particular number of TB cases in the three categories being the most dangerous one. “When I was working in a government hospital, I have seen health officials put patients diagnosed as category one (severe TB) in category three (mild TB) and vice-versa for the sake of maintaining record. The health official would say that he was forced to do that to maintain the standard number of cases in each categories as decided by higher authorities,” recalls an expert.

This can be very dangerous as mild patients were made to undergo medication for eight months and severe cases were having it for six months, the expert added. He feels that the rule of giving treatment only to patients with permanent addresses resulted in many a patient being denied treatment.

Experts say that the very purpose of expansion of DOTS coverage would be defeated unless the government takes the initiative in creating awareness about the centres, adapts the programme to the needs of the children and ropes in private practitioners (PPs).

While more thab 60 per cent of the TB patients go to PPs for treatment, the exclusion of PPs has resulted in poor accessibility of DOTS. According to the ‘Uplekar and Shepard’ study, 100 private physicians in the Dharavi slums in Mumbai prescribed 80 different anti-TB regimens; most were both inappropriate and expensive. A study done by LRS Institute of Tuberculosis and Allied Disease in 1998 also revealed major differences in the treatment strategy by 214 private practitioners in Delhi.

Says Jayashree Parab, medical-social worker, Karm, one of the first NGOs to sign a memorandum of understanding with the Brihanmumbai Municipal Corporation to act as a DOTS provider, “PPs seldom refer their patients to centres offering DOTS because of potential loss of income. And because of irregular treatment, most of the time, when the patients come to us, they are already having Multi Drug Resistant Tuberculosis.” It is only a few private hospitals (Mahavir hospital, Hyderabad) and NGOs (REACH) and the Pimpri-Chinchwad Municipal Corporation, which are trying to forge an alliance between the private and public sector.

Children are also not receiving the benefit of DOTS as RNTCP centres neither provide drugs in syrup form nor permit breaking of tablets, making the administration of accurate pediatric doses impossible. “Most children with TB are also sputum-smear negative. Doctors must rely on clinical acumen when deciding whether or not to start TB treatment,” says an expert. Beneficiaries of CGHS, ESIS and defence (except AFMC-Pune) are deprived of the access of DOTS as the said schemes have not started implementing DOTS.

According to Dr Sheela Rangan, senior scientist at the NGOs, namely Centre for Health Research and Development (Mumbai) and the Maharashtra Association of Anthropological Studies (Pune), the government’s strategy to have microscopy centres as per the population (one centre per 1,00,000 population) has hit the detection of TB.

While initially PHCs were also operating as microscopy centres, now only district hospitals are having microscopy centres at the village level. “It is extremely difficult for a villager to trudge to a district hospital for diagnosis. And considering the fact that one has to go thrice for a sputum test, that makes detection all the more difficult,” says Dr Rangan.

The new guideline has resulted in crowding of microscopy centres in the urban setting, with small dispensaries without any proper infrastructure being forced to operate as microscopy centres, say analysts. Reportedly, the unions of small labs are up in arms, being forced to run a microscopy centre. “As a mark of protest, they are keeping the lab open for not more than two hours,” says an expert. Experts rue that some microscopy centres are run within municipal school premises. “Imagine the kind of infection that a school-run microscopy centre can expose to students,” asks an expert.

Dr Saroj Dhingra, Information Communication and Education official, RNTCP, New Delhi, refused to comment about the accessibility of DOTS.

For more articles on World Tuberculosis Day read April 1-15 Issue of Express Healthcare Management

rita@expresshealthcaremgmt.com