Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness of Community Health Workers in Tuberculosis Control in Bangladesh

Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness of Community Health Workers in Tuberculosis Control in Bangladesh

Article excerpt

Voir page 449 le resume en francais. En la pagina 449 figura un resumen en espanol.


Tuberculosis (TB) remains a major public health problem in Bangladesh. This is exemplified by the statistics for 1993, when the incidence was estimated to be 220 people per 100 000 population (1). To address this issue, the Bangladesh Rural Advancement Committee (BRAC) first initiated a pilot community-based TB control project in 1984 in Manikganj thana (subdistrict), with technical support from the Research Institute of Tuberculosis in Japan (2, 3). This model is currently being applied in 60 thanas covering a population of approximately 14 million (about 12% of the population of Bangladesh).

Since 1993, a national TB programme has been implemented at the thana level, based on the WHO-recommended DOTS strategy, with each thana covering a population of about 250 000 (4). Nongovernmental organizations (NGOs), including BRAC, are collaborating with the national TB programme. Both BRAC and national TB programmes use the same treatment regimens (5), but BRAC mainly relies on the use of community health workers (CHWs) to deliver directly observed therapy (DOT) while the government provides DOT mostly through thana health complexes. According to national TB programme reports, recent cure rates of between 71% and 75% have been achieved (6-8). In contrast, a cure rate higher than the WHO target of 85% has been achieved by BRAC, using CHWs (2, 5).

In the present study, we examined the cost-effectiveness of using CHWs for TB control, by comparing the costs of BRAC and government services.


TB control through government thana health complexes

The government thana health complexes had 31 beds for inpatients, and staff positions for nine medical doctors. Below the thana level, services were also available at union subcentres and family welfare centres, managed by doctors or paramedics (8). Below the union level, there was about one health worker (health assistant) for every 5000-6000 population, who provided basic health care to the villagers (9).

Patients suspected of having pulmonary TB submitted three sputum specimens within two days to the thana health complexes for laboratory examination, and were diagnosed as sputum positive if two specimens were positive for acid-fast bacilli (6). If symptoms persisted, but the sputum was negative for acid-fast bacilli, patients underwent chest radiography at the private or government health facilities. However, systematic quality control of laboratory services has not yet been established at thana health complex level.

An 8-month, short-course treatment regimen was used for treating sputum-positive patients, who underwent followup sputum examinations at 2-3, 5, and 8 months (4). In the first 2-3 months, sputum-positive individuals were given drugs weekly at the thana health complexes, while sputum-negative patients were given drugs monthly, after which patients collected drugs monthly from the thana health complexes. Government health workers traced defaulters.

TB control through CHWs

Each BRAC health centre had a medical doctor or a manager and services were mainly provided by CHWs under the supervision of paramedics (programme organizers). The CHWs were mostly illiterate women who each covered about 200 households (2). In the study area, BRAC had two health centres to provide health care services to the community. Sputum collection centres were widely available, to increase access.

Suspected TB patients were given sputum containers for two samples and asked to bring them to the sputum collection centre, where a third sputum sample was collected. Sputum smears were prepared and sent to the thana-level laboratory for staining and microscopy. If symptoms persisted, but the sputum was negative, patients were referred to the thana health complexes or district hospitals. For quality control, 50% of positive, 5% of negative, and 5% of follow-up sputum slides were cross-checked by another laboratory technician every month (2, 5). …

Search by... Author
Show... All Results Primary Sources Peer-reviewed


An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.