Faruque A, Islam MA, Barua MK, Alam MA BRAC, 75 Mohakhali, Dhaka-1212, Bangladesh

1. Community-Based Tuberculosis Care in Achieving High Case Detection and Cure Rates in Bangladesh Faruque A, Islam MA, Barua MK, Alam MA BRAC, 75 Mohakhali, Dhaka-1212, Bangladesh e-mail: health@brac.net

2. Background Piloting community based TB program • BRAC initiated a pilot programme in Manikganj upazila (sub-district) covering 220,000 population in 1984 Aims of pilot program • to make TB diagnosis and treatment available and accessible to the community • to encourage community participation in the care of TB patients National DOTS achievements (1993-2003) • Case detection rate reached to 38% • Treatment success rate reached to 84%

3. Expansion of DOTS Coverage DOTS coverage (by 1998) • BRAC covered 60 upazilas (15 million population • Others NGOs 126 upazilas • Government Upazila Health Complex covering 274 upazilas Scale up of NGO collaboration by 2003 • BRAC covering 283 upazilas & part of 5 cities (78 million population) • Rest 177 upazilas and part of 4 cities covered by other partner NGOs

4. Study questions • What was the impact of the BRAC community-based approach on case detection and cure rates? • How does the indicator trends compare to the national average? Methods • Cohort analysis of existing TB records was done for all patients registered in between 1998 and 2002.

5. CHW-Community Health Worker(Nucleus of BRAC TB program) • Average age of 35 years • Selected by community • Acceptable to them • Willing to provide voluntary services • Literacy preferred • Trained on common diseases including TB • Provides basic health care services to 300 households

6. Social Mobilization and Diagnosis Social mobilization and suspect referral • Health staff and CHWs give education to the community • Conduct meeting with village doctors, private practitioners, teachers and community leaders • Suspects referred by CHWs and other stakeholders Sputum collection and examination • Sputum collected at outreach centers in every union and upazila health complex • Sputum examined at upazila laboratory

7. DOTS by CHW • Treatment is initiated under health staff and Medical Officer • CHW ensures DOT • Patients come every/ alternate morning at CHW’s home to swallow drugs • CHW ensures swallow of drugs at patient’s home if severely ill • BRAC staff follow-up patients and CHWs twice a month

8. Incentives for Ensuring DOTS Deposit scheme • Financial bond of Taka 200 (US$3.5) as guarantee of treatment completion paid by patients • On completion Taka 125 is given to CHW • On completion Taka 75 returned to patient Pattern of deposit money paid1994(n=53)2003(n=1094) Tk. 200 44 (83%) 1019 (92%) Tk. 150 1 (2%) 12 (1.1%) Tk. 100 8 (15%) 17 (1.6%) Waived 0 (0%) 46 (4.2%)

9. Results: Case Detection Rate in BRAC Areas and National Average

10. Results: Treatment Success Rate In BRAC Areas and National Average

11. Conclusions • CHW approach shows increased case detection by 33% over 4 years, as compared with the national average, which increased by 4% over the same period • Cure rates in the CHW area increased from 87% to 90% in 4 years • Delays in diagnosis (from onset of symptom to DOTS initiation) decreased from 85 days (1998) to 60 days (2002) in 4 years • Cost incurred by patient is less in CHW area than non-CHW area ($10 vs. $19)

12. Key Factors Contributing to Success of Community-Based DOTS • Ownership and participation of patients, CHW and community in DOTS • Rigorous social mobilization increased awareness of TB • Community based approach by CHW increased accessibility to DOTS • Financial bond for treatment completion and incentive scheme for CHWs • Support from government and donors