A case for patient-friendly service

Though the Directly Observed Treatment, Short-course (DOTS) strategy is the most appropriate in controlling tuberculosis, DR. UMA KRISHNASWAMY discovers during a panel discussion with doctors and experts that it is difficult to balance the urgent need for expansion with the equally important need to ensure quality in large countries like ours.

The panel:

* Mr. D. Gupta, Joint Secretary, Ministry of Health & Family Welfare, New Delhi (he faxed the answers to the writer)

* Dr. B. Chandramohan, Deputy Commissioner, Corporation of Chennai

* Dr. C. V. Vasudevan, Health Officer, Corporation of Chennai

* Dr. K. Karunakaran, Asst. Health Officer, Corporation of Chennai

* Dr. T. Shantha Devi, Deputy Director, Tuberculosis Research Centre, Chennai

* Dr. R. Rajeswari, Deputy Director, Tuberculosis Research Centre, Chennai

* Dr. T. R. Frieden, Medical Officer (TB), South East Asia Regional Office, WHO.

UKS: Dr. Frieden, I would like you to start by giving me a global perspective on TB control, with specific reference to the South East Asian countries.

Dr. Frieden: What we see now globally and also in South East Asia is that the DOTS (Directly Observed Treatment, Short-course) strategy is generally accepted as the appropriate policy to control TB. It is being implemented in all the countries of South East Asia and in more than 119 countries around the globe.

The limitation has been in the expansion of DOTS. In large countries it has been difficult to balance the urgent need for expansion with the equally important need to ensure quality. That always produces a bit of dynamic tension, and India is no exception.

UKS: The verdict of the recent joint review (by national and international experts) of the Revised National Tuberculosis Control Programme (RNTCP) is that it is being implemented successfully. What has the epidemiological impact of the programme been?

Dr. Frieden: If the RNTCP covers the whole country by 2005, there could be a saving of at least 2,00,000-3,00,000 lives per year. Over the next 20 years, this means nearly 6 million lives saved!

UKS: What do you think are the weakest areas of the RNTCP? Is it:

a) a lack of political will?

b) a lack of true commitment to the DOTS ideology within the health sector?

c) or an inability to adapt DOTS to different cultural settings that pertain to different parts of India?

Mr. Gupta: The RNTCP is a difficult programme to implement - conceptually, technically, managerially and even sociologically. We must recognise, appreciate and accept this as a challenge.

Political commitment was certainly a weak area. But we need to talk of commitment down the line even to the individual doctor. Political commitment has generally been demanded to ensure adequate resources. With assistance from World Bank, DANIDA and DFID we are planning to cover half the country by 2002 and the entire country by 2005. Expansion, however, must not compromise quality.

DOTS is a new concept and hence it will take time to be accepted. There are sociological implications: patients have to travel; access and timings could be a factor, privacy needs could be an issue.

Eventually, however, DOTS must become a community service. As stigma gets reduced this should become more possible. Finding suitable DOTS providers is perhaps our biggest challenge.

Dr. Frieden: The technical issue is "the patient-centred approach". Once you say that a programme is responsible for every single patient started on treatment, then you have to provide very effective, patient-centred, patient-friendly services. Treatment observation has to be accessible and acceptable to the patient and accountable to the health system. From a technical standpoint the biggest challenge is in ensuring treatment observation.

Policy wise, the issue is one of political commitment, globally as well as nationally. Within the country, it is important that TB is given a high priority, that effective managers are in place, that they are supported, that the programme is reviewed and that policies that are proven to work are followed.

UKS: Let us move on to the theme of forging partnerships with the private sector of health to stop TB. There can of course be two levels of partnerships: at institutional level and at the level of the individfual private practitioner.

In India, some private practitioners are unaware or even sceptical of the RNTCP guidelines. They are also an independent and heterogeneous group who as yet are not deeply involved in the national TB control programme despite their immense potential. Therefore, will it not be far easier to implement the DOTS protocol through institutional intermediaries rather than individuals at least initially?

Mr. Gupta: For proper coverage of RNTCP in an area, both sectors (government and private) must adopt it. This is easier said than done. We are still trying to find answers to the question of how to mobilise the private sector. We will examine the possibility of having a coordination committee. This coordination with the private sector has to be done in a de-centralised manner.

Dr. Frieden: Having an institution to serve as a link between the public and the private sector is very important. Because an institution may be more flexible than the Government, it may be more trusted by the patients and the private sector. But just as treatment observation may be different in every community so also public private links may be different in every community.

UKS: Dr. Rajeswari, the Mahavir Hospital model in Hyderabad and the ACT model in Chennai are the only two formal working models, looking at whether the RNTCP protocol can work in a partnership between the Government and private health sectors. Can you give me a critical evaluation of these models?

Dr. Rajeswari: It is absolutely necessary to take into our (RNTCP) fold the private sector. The two models have shown how we can do this nicely.

The Mahavir Hospital has trained approximately 100 private practitioners. They have opened up neighbourhood DOTS centres, which are very popular both from the patient's angle and the private practitioner's angle. They have reported a 85 per cent cure rate.

The ACT model has also done very well but on a different pattern. They have trained 52 practitioners, who volunteered to be part of RNTCP. What we observed is that community volunteers are very responsible and they have taken DOTS as a challenge!

UKS: Let us focus our attention locally on the innovative work undertaken by the Chennai Corporation. Dr. Karunakaran, Dr. Vasudevan, the two of you are involved in the day to day implementation of RNTCP in Chennai. What is your experience when you work in conjunction with the private sector institutions?

Dr. Karunakaran: After involving the private sector, our field staff feel satisfied because the NGOs are supportive of their work. I feel that more private practitioners should be advocated on the DOTS methodology.

Dr. Vasudevan: We found out that our medical officers and fieldworkers were very enthusiastic. If there is any defaulter, they go to his house the same day and retrieve them the next day for treatment. We have to involve more voluntary organisations and they should also be willing to cooperate.

UKS: Dr. Chandramohan, it is worrying to note that a sizeable segment of TB patients in Chennai do not have the benefit of DOTS for various reasons. What measures has the Corporation instituted to bring the benefits of the RNTCP to the citizens of Chennai?

Dr. Chandramohan: Basically there are two problems: physical accessibility and financial accessibility. With reference to physical accessibility, we have been able to put in a lot of infrastructure: 10 TB Units, 14 designated microscopy centres and around 60 DOTS centres in Chennai. With this kind of infra structure, we have taken care of the physical accessibility part.

It is quite obvious that a significant section of the population go to a private practitioner. But once diagnosed as having TB, they find it financially difficult to afford the medicines. Such patients must also be given the benefit of a proper drug regimen. We are tying up with private practitioners to do this.

UKS: Dr. Chandramohan, the Corporation TB Units suffer from an image problem. The public view them as inadequate in terms of the technical infrastructure, while in fact you have state of the art equipment for smear microscopy. You also supply top quality anti TB drugs free of cost to patients. What are you doing to change the false public image?

Dr. Chandramohan: The primary responsibility, is to offer the best services to patients and the next is to be able to project an image that it is offering, in fact, the best services. We are undertaking a lot of information, education and communication activities by which we not only seek to educate the people about various health problems but also develop in them health seeking behaviour. We have taken up a campaign, through the print media and the audio-visual media.

Once we are able to train our staff to be a little more polite, a little more caring,then by word of mouth, we expect to counter this kind of negative image that persists in the minds of the people.

UKS: What are your suggestions on monitoring partnerships between the Government and private sector? Should there be an apex body at national level? Will monitoring be easier if there is mandatory notification of TB? Some people have suggested that it would be reasonable to have a single administrative cum medical channel through which all TB patients in the country will pass.

Dr. Chandramohan: This monitoring of government-private sector partnership is a dynamic situation which should not touch either extreme. If it is too lax there is inadequate supervision, if it is too tight, the private sector may resent it. I think that over a period of time, we can strike at a dynamic balance, which can ensure accountability for delivery of the drugs to the recipient.

If we have systems in place and this is by and large a system which is built upon voluntary mobilisation and self conviction brought about through health education, notification is not needed.

Functionally in India, most of the TB patients are passing through a single administrative and medical government channel. But, being a democracy and being a country where citizens have various options, some people who can afford to are going through other channels. We need not restrict ourselves but we only need to regulate ourselves for efficacy and effectiveness.

Dr. Shantha Devi: There is a need for an apex body. But, this should not look like a policing unit. We have clearly seen in the ACT model, that as long as there is no "big brother" attitude, and that it is facilitatory unit which links the two sectors, it will work.

TB is a notifiable disease (Tamil Nadu Public Health Act of 1939). Notification was tried in Delhi recently, but it did not meet with success, because of the social stigma attached to it.

Dr. Frieden: Ideally, every TB patient in a district should be registered. That is possible with or without mandatory notification, by having active monitoring of all laboratories that do smears for TB. Now ACT has begun doing that. That is a very encouraging start.

UKS: Are there gender disparities in TB management in South East Asia? What are your suggestions to make the TB control programme in India more gender specific? What role can women's groups play in empowering local women or addressing these gender disparities?

Dr. Shantha Devi: The experience in gender bias is from other parts of South East Asia and not from India. We have found that the action taking pattern of chest symptomatics in the community is not different between the two sexes. At the sociological level there is stigmatising of women.

Dr. Rajeswari: In one of our studies on the socio economic impact of TB, we found that nearly 75 per cent of the women are shy to discuss their problem fearing rejection and that actual rejection had occurred in nearly 15 per cent of the patients! I think that there should be support groups for women who face rejection. TB is eminently curable. That concept should take deep root.

Dr. Chandramohan: If a woman is being discriminated against, the intervention should be in the area where this stigma is being generated. So we should concentrate on creating awareness to remove stigma. We would like women's groups to get involved in motivating women to go in for a successful completion of the programme.

Dr. Frieden: It is particularly difficult for young women to get TB treatment confidentially. The programme needs to be sensitive to establishing means of ensuring confidentiality of patients, especially young women.

UKS: Dr. Chandramohan, may I ask what the future plans of the Corporation of Chennai are in terms of ideology and implementation of TB control in the city?

Dr. Chandramohan: We would like to ensure that every single case is identified, diagnosed and treated. We would like to further improve our information, education and communication activities so as to ensure that the stigma which is the main drawback today for the treatment and diagnosis of TB is removed. Operationally of course, we would like to improve our delivery systems by expanding our infrastructure and training our people to treat patients with a smile.

* * *

Just like cough or cold

THE following is what the Mayor of Chennai, Mr. M. K. STALIN, wrote back by way of response to the queries posed to him on TB control.

What are your plans to control the spread of Tuberculosis in Chennai?

My council and I realise the importance of controlling this dreaded disease. We are totally committed to this programme and as on date we have been able to ensure that 85 per cent of all newly detected sputum positive cases have been converted to sputum negative. We plan to achieve cure rates in the region of 90-95 per cent in the near future.

What is the kind of support that you are giving to the programme?

We have received about 90 lakh rupees from the World Bank for the scheme and have opened 10, Tuberculosis units. (One for each zone), 14 microscopic and diagnostic laboratories. We have procured and started supply of the good quality anti tuberculosis drugs. The cost of drugs works out to Rs. 3,600 per patient. They are supplied free of cost to the patients at our 63 treatment centres and nine Government hospitals. We have also tied up with 60 private practitioners to cover the population attending their clinics.

What do you have to say regarding the stigma that is attached to the diseases?

Due to superstition many believe that tuberculosis is something to be ashamed of. It is a disease just like cough, cold or fever. It is completely curable and people should come forward to get treatment. This will benefit them enormously as the earlier the disease is detected the sooner it can be cured.

* * *

What they say

Experiences shared by patients on DOTS in Choolaimedu P.H.C., Chennai Corporation.

Mrs. Jaya, employee in Nutritional Department, mother of three children and resident of Choolaimedu, says:

"I was treated for TB 10 to 15 years ago. Sometime back, I was not feeling well and I suspected that the disease may have recurred. So I went to Chetput (TB) hospital for a check-up. From there I was referred to Choolaimedu PHC. Here sputum test and X- ray was done. Treatment was started.

"I felt that coming to the PHC and taking the medicine is a good system because otherwise people may throw away the medicines without taking it. So I come at 9 a.m., take the medicines and go to work. My family is aware of the fact that I am taking medicines but the neighbours do not know about it. I cannot think of any problems in coming and taking medicines in PHC."

***

Shamundeshwari, housewife, mother of child and resident of Choolaimedu, says:

"I had lot of phlegm and a cough and underwent treatment with different doctors for this. Then I went to Chetput. From there I was sent to this PHC. Here they did the sputum test and I started taking medicines. I come every morning at 9 a.m. to take the medicines. My family members know that I am under treatment and they encourage me to be regular. My neighbours do not know about the disease, but they do know that I am taking medicines from PHC. Any one interested in their personal well-being will take the trouble to come and take the medicines regularly."

***

Mr. Bhupathy, a 32-year-old

privately employed man from Arunachalam Nagar says: "I know that I have TB. My neighbour told me to come here. I come here at 7.30 a.m. to take the medicines. It takes 5 minutes to reach the centre from my house. My work was not affected in any way. My family members know about the treatment. I have not encountered any problem in taking the medicines. I did not have to spend any money at any point of time."

***

Mr. Jothilingam, aged 18 years, a Plus Two student, from Periyarpathi says:

"I had continous fever for sometime. My brother took me to a private doctor. The Private doctor asked me to come here. If people are asked to take medicines by themselves, they may throw it away. I come everyday at 3 p.m. after school to take the medicines. I feel much better, now stronger also My family members know about the treatment but my friends do not know about it. I have encountered no problems in taking medicines from this centre."

***

Mr. S. Selvaraj, aged 51 years, a Barber from Bajanai Koil Street and father of 6 children says: "I began to lose a lot of weight. My friend took me to a private doctor who asked me to go Chetput (TB hospital). There they did a sputum test. I was referred to this place. I take the medicines from the P.H.C. So, I come regularly, It does not affect my work. Everyday at 9 a.m. I start from home. It takes 15 to 20 minutes to reach this place. In the intensive phase, I used to feel very sick. I began to feel better during the third week of treatment."

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