Academic journal article Bulletin of the World Health Organization

Turning Liabilities into Resources: Informal Village Doctors and Tuberculosis Control in Bangladesh/Medecine Informelle et Lutte Contre la Tuberculose Au Bangladesh Ou Comment Transformer En Ressources Des Elements Consideres Comme Des handicaps/Aprovechar Al Maximo Los Recursos: Medicos De Aldea Informales Y Control De la Tuberculosis En Bangladesh

Academic journal article Bulletin of the World Health Organization

Turning Liabilities into Resources: Informal Village Doctors and Tuberculosis Control in Bangladesh/Medecine Informelle et Lutte Contre la Tuberculose Au Bangladesh Ou Comment Transformer En Ressources Des Elements Consideres Comme Des handicaps/Aprovechar Al Maximo Los Recursos: Medicos De Aldea Informales Y Control De la Tuberculosis En Bangladesh

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Introduction

Bangladesh ranks fifth among the 22 highest tuberculosis-burden countries in the world with an estimated tuberculosis (TB) incidence rate of 246 cases per 100 000 population. (1) The country adopted the DOTS strategy for TB control in 1993. Since then, the National TB Programme has expanded to cover almost the entire country, mainly through two large nongovernmental organizations (NGOs): the Damien Foundation Bangladesh, a Belgian NGO covers 26 million people and the Bangladesh Rural Advancement Committee (BRAC) covers 82 million. Global targets set by the World Health Assembly for 2005 include detection of at least 70% of infectious TB cases and successfully treat over 85% of these. Despite improvements in the TB services offered by the National TB Programme and collaborating NGOs, the smear-positive case detection rate in Bangladesh was only 33% in 2003 and the treatment success rate was also slightly lower than expected--84% in 2002. (1)

Like most countries in south Asia, Bangladesh has a large private health sector that exists in both rural and urban areas. This sector comprises formal and informal individual private practitioners as well as private commercial and voluntary institutions. Estimates show that in Bangladesh, 50% of doctors, 42% of nurses, 65% of paramedics and 100% of informal (non-qualified and unregistered) "gram dakter" (Bangla for "village doctor") are in the private sector. (2) Gram dakter are by far the largest group of health-care providers. This group is made up of semi-qualified or unqualified allopathic practitioners, drug vendors and practitioners of non-allopathic or mixed systems of medicine. Because village doctors are usually close by and provide inexpensive services, they are the most commonly used care providers in rural areas, especially among the poor. (3,4) And with more than 75% of the population of Bangladesh living in rural areas, village doctors provide most of the outpatient health care in the country as a whole. However, the poor quality of their services, delays in TB diagnosis and irrational use of drugs have all impeded TB control.

The Damien Foundation recognized the potential of these "non-doctors", who are well accepted by people in rural areas, to improve access to quality TB care in villages. Thus, the Damien Foundation launched a special initiative to make use of village doctors in TB control. Here, we report how this initiative turned village doctors, a previous liability for TB control, into a resource that contributed substantially to DOTS implementation.

A programme for TB diagnosis and treatment

Setting

The Damien Foundation has collaborated with the National TB Programme of Bangladesh since 1994 in implementing DOTS in a population of about 26 million people. The allocated area is divided into four project areas: each has a director assisted by two medical doctors, one field coordinator and several TB supervisors. Every supervisor looks after a population of 750 000--1 000 000 with the help of about nine TB health workers. TB drugs and laboratory supplies are provided by the National TB programme.

Enlisting village doctors

There is at least one village doctor for every 2000 people and they are often first contact for patients with symptoms of TB. That they live within and have a rapport with communities makes these health workers suitable for providing directly observed treatment (DOT) close to patients' places of residence.

To engage village doctors, we compiled a list of all these workers using information obtained from the village doctors' association and from drug companies. We sent invitations to batches of 30-40 village doctors, requesting their participation at a one-day orientation and training course on TB. The training took place in the government health centres and was facilitated jointly by the centres' health and family planning officer and the NGO staff. …

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