Customer orientation in health programmesa study of the revised national tuberculosiscontrol programme in Hyderabad and Medakdistrict of Andhra Pradesh

Abstract

Tuberculosis is a major public health problem in India. With anannual infections of over two million new cases and nearly 5 lakhdeaths, it is causing enormous disruption. All this is entirelyavoidable as TB can be easily cured with proper medicineswithout a great cost. However, since TB usually affects thepoorest people, and the treatment is prolonged, most of thepatients tend to discontinue treatment before they are completelycured of the disease. Though 90 pct. of the patients seek medicalattention within one month of the onset of the symptoms, thehealth systems, both in the Public and the Private sectors, are notable to diagnose and start treatment immediately even afterconsiderable expenditure by the patients.The National Tuberculosis Programme, which existed since 1962was plagued with several problems and it is estimated that on anaverage, it has diagnosed 30 pct. of the patients and completedtreatment in case of about 30 pct. of the cases registered with theprogramme. Most of the patients typically approach one ofIndia's 10 million Private Doctors as a first choice. However,private doctors usually rely on chest x-ray which is not a reliabletool of diagnosis vis-a-vis the sputum microscopy, prescribeinappropriate and expensive medicines, have no mechanism toobserve treatment, do not feel that it is their duty to educatepatients and do not maintain any records. As a result, it isimpossible to say how many TB patients are actually completingthe treatment with the private doctors. It is in this back groundthat the Revised National Tuberculosis Control Programme hasbeen launched in India on a pilot basis in the year 1993 andbeginning from 1998 the Programme has expanded rapidly tocover 60 pct. of the population by January 2003 and it is proposed tocover the entire country by 2005. The new Programme followsthe principles of DOTS (Directly Observed Treatment-SortCourse Chemotherapy), which have proved effective incontrolling TB in many countries across the world.VIFor my dissertation, I have chosen to study the performance of theDOTS system being implemented in Hyderabad and Medakdistricts of Andhra Pradesh for the past 7 years. The main findingsof the study are: even though the DOTS programme is inoperation in both these districts for a considerable period of time,they have not achieved the targets set for the programme both interms of cure of 85 pct. of the new sputum positive cases anddetection of 70 pct. of the new sputum cases. Relatively speaking,the cure target is much closer to achievement (around 80 pct.) thanthe detection target, which is only around 60 pct. of the target. Theprogramme managers should take immediate steps to find outways to achieve both the targets, as failure to do so will result incontinuation of the chain of infection in the community and willresult in the spread of multi-drug resistant strains of TB whichwill be impossible to control even if unlimited resources are spenton it. Effective TB control is also imperative in view of the HIVepidemic, which has already spread to more than 4 million peoplein the country who stand much greater chances of developingactive tuberculosis disease.Other findings of the study are as follows: All the 84patients surveyed in the sample are satisfied with the supply ofmedicines, more than 98 pct. of patients have said that they aresatisfied with the DOTS system of treatment of TB. 98 pct. of theHyderabad patients' treatment of the intensive period is directlyobserved where as only 70 pct. of the Medak patients' treatment isdirectly observed. Television is the preferred medium of TBpatients as 70 pct. of the urban sample and 30 pct. of the rural samplehave television sets but barely 3 pct. of them have seen any messageregarding TB on television indicating a lack of any Information,Education and Communication (IEC) activities for theprogramme.