Tuberculosis Control and Community Participation
N.Ishikawa
Why community participation?
Althogh DOTS has been proved to be effective and feasible. TB case burden in many area in the world has been increasing, particularly HIV prevalent area or service coverage is not sufficient due to the limited resources. Against these, community-based care indispensable for controlling TB effectively.
Community participation is needed due to the limited nature of health services system deliverd by the government. It has a wide gap to reach the bottom community. How can the essential health care reach to the community? The alternative concept of service delivery was stressed in PHC movement; i.e.(1) people have a duty as well as right to participate in solving their own problems, and moreover; (2) they have the capacity of assessing their health needs, mobilizing local resources and proposing new solutions. So it is through community participation how the above mentioned gap is overcome and essential care can be available to the people.
Community Participation (CP) for What?
CP therefore is needed in TB control for wider coverage, easier accessbility and cost effectiveness. Moreover, it promotes ownership of the programme by the people, resulting in more sustainable management of the programme.
Who are Community or People?
There are many representing community. I would put more importance on community based organization in periphery or local community such as village or district, rather than NGOs or TB association.
What can community do?
Community can provide DOT, sputum collection or health education to people. But more importantly they can run TB programme under them in a way of lacal TB programme Committee. In South African experience, storekeeper and CHW can be a better DOT supervisor.
Bangladesh Model of GO and NGO Collaboration; in the case of BRAC
In Bangladesh, Thana Health Complex (THC: Sub-district hospital covering 250,000 population) is the lowest unit for TB programme, where most of the patients should come for taking drugs. But it is too far for many people for daily DOT. An alternative approache has been tried through NGOs. BRAC for example is a community development organization with health and TB programme as a component. They develop a Shasto Shevika (health volunteer: SS) in their community groups, and SS provide DOT to the patients in their own villages.(The deatail will be presented in poster session by Akramul Isiam.) BRAC as an organization, coordinate with the government and district health authorit, following NTP with drug supply from NTP. They cover already 15 million people in 60 Thanas among 460 Thanas. Their cure rate is successfully high enough as high as 86.7%. And the programme is useful not only for TB but for womens' development or community development. Other programmes in African countries or China show the use of community people as a potential DOTS agent.
NEPAL Model (Nawarparasi District Case)
Nepal government encourages CP in various programmes. In Nawarparasi district, where RIT has been involved, each treatment unit (district TB clinic and health post) has its own DOTS committee consisting with local people, such as village committee member, local news paper reporter, social worker or cured patient. On world TB day, many of those committee mobilised local funds for activities. They are obviously supporting the patients and TB programme itself. However for this, governement local staffs role is crucial in motivating and supervising the local potential members.
How are the staff motivated for community involvement?
For the staff to be motivated in community involvement, he/she must have a good experience in participating in the programme; i.e. staff participation should be aimed first. For this purpose his/her bosses' attitude should be both ways of top down and bottom up. Participatory action research with their full involvement in identifying the problem and proposing the solutions in local apprication of DOTS will help the staff to be empowered. TB association and other NGOs should have a role to motivate local community to participate.
DOTS needs CP
When TB programme its self is very weak or insufficient. CP has little value. However, When DOTS is started, then CP works as its real driving force.
Conclusion
There need more attention and more importance to be put on CP. Unfortunately only few reports are available though there must be many cases with interesting and successful CP. More documentation is needed on the existing experience. Further operational studies must be needed on the effective partnership with NGOs and community organzations.
