rural sector through affordable and quality healthcare services

An evidence providing research to reach the unreached in a high prevalence district of India.

Mohammed Shahnawaz
Fellow Program in Management Health & Hospital Institute of Health Management Research BACKGROUND Tuberculosis (TB) - an infectious airborne disease - remains a major global health problem. It causes ill-health among millions of people each year and ranks as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV). Each year, there are around nine million new cases of TB, and close to two million deaths. All countries are affected, but 85% of cases occur in Asia (55%) and Africa (30%).

India accounts for one-fifth of the global TB incident cases. Each year nearly 2 million people in India develop TB, of which around 0.87 million are infectious cases. It is estimated that annually around 330,000 Indians die due to TB. Since 1993, the Government of India has been implementing the World Health Organizations (WHO) recommended DOTS strategy via the Revised National Tuberculosis Control Programme (RNTCP). Phase II of the RNTCP started in the year 2005 is a step towards achieving the TBrelated targets of the Millennium Development Goals (MDGs). Since 2006, RNTCP is implementing the WHO recommended Stop TB Strategy, which in addition to DOTS, addresses all the newer issues and challenges in TB control. There are significant numbers of districts which report high TB prevalence. In most of the world, more men than women are diagnosed with TB and die from it. TB is nevertheless a leading infectious cause of death among women. Some studies even indicate that women may have higher rates of progression from infection to disease and a higher case fatality in their early reproductive ages. As tuberculosis affects women mainly in their economically and reproductively active years, the impact of the disease is also strongly felt by their children and families. In the case of high prevalent district X, despite the free treatment under the said programme at all government facilities, the program manager perceived that the significant number of women were not coming to Government health facilities, mainly poor, for sputum testing. The recent data of 2010-11of district X vindicating the perception by showing the gap of 12 percent point from the usual universal pattern of reporting. The proposed research is an attempt to identify those undiagnosed missing women under TB control strategy of the district x in order to provide the scientific evidences to reach the unreached/ bridge the gap. RESEARCH QUESTION Why women are significantly missing from the TB control strategy in high prevalence district x? GENERAL OBJECTIVE To know to what extent the women, mainly poor, are not availing the TB diagnosis and treatment service in the district x and to identify ways in which their participation can be improved.

SPECIFIC OBJECTIVES 1. To review the existing model of TB Management Information System (MIS) function in district x. 2. To determine the extent to which government facilities and private service providers (PublicPrivate Mix) share information/report?

3. To determine the extent of response of health worker/care givers to people, especially poor women who approach the facility for diagnosis or when caregivers provide doorstep (if available) service? 4. To identify the previous efforts the facilities taken to increase the number of women reporting for diagnosis. 5. To assess the, if any, cultural constraints in availing the service with regard to women exist in the district. 6. To determine the extent to which NGOs/VOs/civil societies support the TB control strategy with regard to the diagnosis of women? 7. To recommend line of action to improve the participation of women in availing the TB diagnosis/treatment on the basis of findings. METHODS It will follow method Qualitative analytic approach to study the functioning of local MIS system, sharing of information/report among government facilities and private service providers (if there are any such practice follow in district x) in order to develop the more realistic idea of missing women and strengthening the epidemiology study of the TB in the area. a) Qualitative Study: In-Depth Interview & Ethnographic Narratives- Simple random sampling will be done to select government facilities and private service providers from the district x. Ethnographic narrative will be conducted to assess the cultural constraints in availing the services. b) Quantitative Study: A structured questionnaire assessing response behavior of health worker/care giver and NGOs/VOs/civil societies support to the programme will also be administered.

LINE OF ACTION FOR A FEASIBLE OPTION TO DEAL WITH THE PROBLEM: The focus should be on to bridge the gap to reach those who are hitherto considered as missing women. This can done either to attract these poor women to the facilities or to reach the doorsteps of the community for the sputum screening with proper maintenance of their trust and confidentiality in the process. Tuberculosis Contact Investigations can be an option to bridge this gap and with some innovation it can produce good result even in resource crunch setting. Tuberculosis (TB) contacts are people who have close contact with patients with infectious TB. As they are at high risk for infection (and in line with the Stop TB strategy), TB contacts should be investigated systematically and actively for TB infection and disease. Such interventions are called tuberculosis contact investigations. They contribute to early identification of active TB, thus

decreasing its severity and reducing transmission of Mycobacterium tuberculosis to others, and identification of latent TB infection (LTBI), to allow preventive measures.

Not-so-close-contacts Close Contacts Source Patient Tuberculosis Contact Investigation (TCI)

The modern technology of SMS-based (mobile phone)/electronic reporting/recording/sharing of information with local MIS would allow the facility to firstly identify and focus the high prevalence clusters of district x. With the help of TCIs the health personnel can visit the community for doorstep screening and with proper counseling of women by health volunteers/caregivers diagnosed women can visit the facility for further follow up treatment.

NOTE ON THE EVALUATION OF THE IMPLEMENTED OPTION The impact of suggested option of contact investigation will be based on the outcome and evidences of the suggested intervention with following objectives:

To judge the effectiveness of new approach of contact investigation in TB control programme. Does this approach result in more number of women being diagnosed for TB? To assess how well intervention has been implemented. How many of them left out, to delve deep into the reason and what can be done to improve the outcome. To analyse the integrated data and zero in on those source patients through which contact had been made. To analyse the data of women who were diagnosed through contact investigation and follow up the trend of full treatment, if diagnosed positive. To evaluate the rates and timing of TB disease among contacts. Also try to determine the proportion of TB cases which can still be prevented with contact investigation. To judge the outcome in view of its comparison with other similar type of interventions for TB control and improvement of the figure of women participation for diagnosis and treatment.