If there is already a long delay before TB patients in India start treatment, the Directly Observed Treatment Short-course (DOTS) strategy offered by India’s TB control programme does not make it easy for patients to access and complete the treatment. In contrast, patients who took DOTS from private practitioners faced fewer barriers and were more likely to complete the treatment. The results were published recently in the journal BMC Health Services Research.
The study interviewed TB patients who had recently completed or were on the verge of completing treatment. These patients belonged to three groups: 1) those who had reached the public sector directly and took DOTS at Revised National TB Control programme (RNTCP), 2) those who were referred by private practitioners to DOTS centres run by RNTCP and 3) those who took DOTS treatment offered by private practitioners after being diagnosed at public sector.
Despite TB treatment being free, patients and their caregivers faced challenges, and these were related to coping with RNTCP’s DOTS strategy, the paper says. Poor patients residing in rural areas faced the greatest difficulty in overcoming the barriers. They had to travel long distances every alternative day to reach a DOTS centre, had to put up with inconvenient timings and “unfavourable attitude” of RNTCP staff.
With the timing of DOTS centres at RNTCP being fixed (between 9 a.m. and 1 p.m.), patients had to reschedule their daily routine to make the visit possible. Travel plus the long waiting period at DOTS centres meant that patients and their caregivers, who are mostly daily wagers, ended up missing work for at least half a day. “Thus, they were left with a choice either to earn their livelihood or to take the DOTS therapy,” Vijayashree Yellappa the senior author from the Institute of Public Health, Bengaluru writes.
“For people who are daily wagers… work is more important than the tablet and if the authorities refuse to oblige [with the timings], he will quit the tablet and proceed to work,” one patient told the authors.
One way of solving this is by having more number of DOTS centres to increase its proximity to a patient’s residence. But more importantly, there is dire need to bring in more flexibility in terms of timings. In stark contrast to public sector DOTS centres, patients who approached private practitioners for DOTS could tailor their timings to suit their daily schedule. “TB medicines should preferably be taken in the morning. But they can be had at any time of the day after a meal,” says Dr. Yellappa. “So patients seeking care in private sector can continue seeking treatment without losing their daily wages.”
Besides flexibility in timings, proximity to private practitioners was a huge factor for patients seeking DOTS treatment from private sector. Also, immediate medical attention was provided when patients faced side effects, which was missing in case of patients seeking DOTS therapy at public sector. Unfortunately, all the patients who sought treatment from private doctors lived in urban areas.
Counselling, especially in the initial stages of DOTS therapy when patients needed it the most, was simply missing when patients sought DOTS therapy at public sector. “RNTCP does not have qualified practitioners to offer counselling,” she says. The competence of health personnel involved in TB care should be strengthened and better communication between providers and patients should be achieved through appropriate training, the paper says.
“There is a compelling need to decentralise DOTS providers. Whoever is closer to the patients, including private doctors, pharmacists, teachers and anganwandi workers should be allowed to provide DOTS therapy,” Dr. Yellappa says. In one case, a patient’s mother who is a DOTS provider herself was not allowed to give DOTS to her daughter.
The study found that only two patients who had approached the public sector were directed to private doctors for DOTS treatment. “But it happened only because the patients initiated it,” she clarifies.
With stigma and discrimination already being rampant, the national TB control programme has done little to reduce it. In fact, RNTCP is programmed to cause stigma and discrimination. “Whenever patients start treatment, RNTCP staff visit their homes. Since they don’t keep the intent of their visit subtle, everyone comes to know of the patient’s TB condition,” says Dr. Yellappa. “The programme staff should be more sensitive when they approach patients.”
Currently, the emphasis is more on achieving targets than being patient-friendly. This should change and RNTCP should seriously consider a “patient-centred approach to TB control, delivered with dignity and compassion” as its priority if it intends to provide “universal access to quality assured free diagnosis and treatment to patients”.