Objective="Using patients instead of health workers to facilitate drug delivery at a Community Health Centre (CHC)."
Details for Reform Option "Management of Directly Observed Treatment Short Course Programme, Rajasthan"
Under the National Tuberculosis Programme, Directly Observed Treatment Short course (DOTS) has been adopted in 1995 across all states of India. The key components of this strategy are – case detection by sputum microscopy, standardized treatment for 6-8 months, regular supply of essential drugs and standardized reporting system. For ensuring actual injection of medicine to patients suffering from tuberculosis (TB) so that drug resistance is reduced, Auxiliary Nurse Mid-wife (ANM) needs to visit patient’s home on alternative days or once a week to ensure that they take the doses continuously on alternate days or once a week. It is very labour intensive. In addition, because the patient often feels better after one or two months, treatment is frequently interrupted.
To tackle the large amounts of manpower necessary to successfully carry out this course of treatment, the Medical Officer (MO) in charge of one CHC, located in Pali district, Rajasthan, adopted an innovative strategy which requires the patients to come to the facility and take the medicine themselves.
(i) Identifying the Tuberculosis patients and categorizing them according to sputum positive or negative and whether they are first timers or repeaters.
(ii) The medicine for each patient is put in separate boxes and the patients are asked to mark a suitable symbol to identify their box.
(iii) The names of the patients along with their details are written in the box using different colour markers – red for category I (sputum positive); blue for category II (repeaters); green for category III (sputum negative). The symbols of the patients are also made using the same colour scheme.
(iv) The different category boxes are stacked in separate compartments of an almirah (chest of drawers).
(v) Patients are trained to identify their medicine and take out the required dose.
(vi) The patients sit on a bench outside the doctor’s chamber in direct view of the doctor. They come early morning to collect their medicines 8.30 am to 10.30 am.
(vii) While seeing other patients the MO- DOTS keeps watch as to who is taking the tablets. After end of every week MO checks the boxes to verify whether all the patients have come and taken all the doses. If any patient has missed the dose or has not come for sometime to the CHC, ANMs (Auxiliary Nurse Midwife)/MPWs (Male multipurpose workers) are then sent to follow-up.
(viii) Contact number or contacts of people living nearby or contact of teachers or some known person in the village is always taken and if the patient misses one dose he/she is contacted immediately. Hence, workers who would have been giving medicines to each of the patients now just chase up the dropouts.
(ix) Regular maintenance of information on TB patients in the computerized Management Information System.
Patients are regularly taking medicines from the CHC. In addition, CHC reported that the system has generated an interest among patients to come to the CHC and take the requisite dose. The quality of supervision has remarkably improved the status quo of the patients, as there has been reduction in defaulters over a five year period. The data with the CHC shows that three-fourth of the patients have been cured. For more detailed results
Reduces the cost of staff regularly visiting villages.
Villages adjacent to Sadri CHC and also the town. Similar strategy is used in the Sub Centres which are under the Sadri CHC.
Inclusive: Patients involved in making the treatment plan. Encourages a good doctor-patient relation.
Timesaving: Reduces the field workers’ workload.
Effective: Reduces the number of defaulters.
Needs careful monitoring: Chances of dropout unless continuous monitoring.
Needs education: Patients do not always realize the importance of regular medication.
Needs communication: Efficient contact must be made between doctor, institution, patient and prominent people in the villages.
Dedicated and motivated MO.
Cooperative CHC In-charge.
Regular supply of medicine.
Good quality diagnosis.
List of identified TB patients and regular monitoring.
Who needs to be consulted
CHC In charge, Sadri CHC.
MO – DOTS, Sadri CHC.
Sustainable only when there is regular monitoring by MO.
Chances of Replication
Good, in rural and semi-urban areas. In urban areas the patient are very mobile and it is sometimes difficult to track them down. It is replicable mostly wherever there is a motivated MO and cooperative CHC In charge.
The TB control programme started in Rajasthan in 1966. However, lack of adequate funds, political wills erratic supply of drug, inappropriate IEC and supervision and monitoring were some of the reasons for the programme’s inability to achieve its goals. In 1995, the TB programme was reviewed and DOTS strategy was drafted and was expanded in phased manner with decentralization of service delivery system. As of now the State has a TB cell, TB demonstration and training centre, 32 district TB centres, 143 TB units, 650 Microscopy centres, 1843 treatment centres and DOTS services provided at 11296 sites across the state. Quarterly newsletter was started since 1993. Few innovative approaches adopted – IPC slip, IEC homes and fixed tour programme.
Dr Nandini Roy, HS-PROD Research Consultant, NIMS, September 2005.
Last Updated: Prabha Sati, Research Consultant, ECTA, December 2006.