Poverty impedes access to existing tuberculosis (TB) services
Poverty not only makes poor people more vulnerable to tuberculosis (TB) but also makes them less likely to access the existing TB-related prevention, treatment and care services. There is substantial number of active TB patients that are still not reached by existing TB control programmes. Efforts to scale up might mean a very well coordinated and community-centric approach so that those vulnerable communities who aren't benefitting from the existing healthcare services are reached and served optimally. This was a key thrust in varied sessions of the consultative workshop of TB and Poverty sub-working group of the Stop TB Partnership which was held in India (29-30 October 2010).
Before the 41st Union World Conference on Lung Health opens in Berlin, Germany (11-15 November 2010), listening to these TB programme managers on how the poorest of the poor, particularly from marginalized or vulnerable communities are least likely to access existing services, makes it clear that engaging affected communities with dignity as equal partners in fight against TB is so vital.
Poor people are more likely to face financial barriers to access existing prevention, diagnostic, treatment and other TB-related care services. Even if anti-TB treatment is free, costs like those for transportation, loss of livelihood, among others can disrupt access to existing TB services.
In parts of Indian states of Bihar, Chhattisgarh, and Jharkhand, and in Nepal, participants at the consultative workshop of TB and poverty sub-working group, shared their experiences that the poor people can’t access TB care due to the geographical barrier of distance from the health centre and at times, they also face cultural barriers to accessing care owing to stigma (although stigma has been addressed effectively too to considerable extent in many settings).
In Jharkhand, the State TB Officer Dr R Dayal said that they have adopted innovative ways to reach out to the poor. Rickshaw pullers, tobacco shops, and ex-TB patients are engaged to reach out to those people who might have TB and aren’t receiving care from existing services. In Jharkhand, the rickshaw puller and the tobacco shop owners have been trained optimally to provide DOTS therapy as well.
In Jharkhand, Dr Dayal says that if required, TB patients are provided cash compensation to cover costs related to travel, loss of daily wages or to manage adverse reactions or complications during anti-TB treatment.
In Chhattisgarh, Dr DN Dewangan, the State TB Officer, said that 47% of TB cases are being missed by the state TB programme. Either these 47% of TB cases aren’t able to reach the health system or are being managed by the private qualified or unqualified healthcare providers.
However, the Chhattisgarh state TB programme has taken several steps to ‘reach the unreached.’ There are designated microscopy centres (DMCs) established among the refugee communities such as those living in the Mainpat Tibetian camps and Mana Bangladeshi camps. The State TB programme reaches out to the jail or prison inmates with DMCs in both Central Jails in Bilaspur and Raipur in Chhattisgarh state. The state of Chhattisgarh has 32% tribal population so the state TB programme has established one DMC for every 50,000 population and travel cost is provided to the tribal people when they access these services.
Strengthening of advocacy, communications and social mobilization (ACSM) activities in urban slums and tribal populations, waiving user charges for X-ray during diagnosis of TB and linking of TB patients with existing nutritional support schemes are other key measures that are helping reach the unreached TB patients in Chhattisgarh state.
Engaging affected communities with dignity as equal partners in the fight against TB can potentially help the TB services to reach the unreached. The Patients’ Charter for TB Care, a rights and responsibilities based framework, is an integral component of the WHO Stop TB Strategy, but most TB high-burden countries haven’t invested enough to roll the Patients’ Charter out. Unless the TB services ‘reach the unreached’ TB patients, the epidemic will continue to pose the challenge. And the solution probably lies in a community-centric, locally driven and well coordinated approach.
BOBBY RAMAKANT - CNS