Thailand - Stop TB Partnership

Community-based DOTS
TB should not be seen as an ‘experts-only’ disease; it affects everyone and
everyone has a role to play.
—Jamillah Mwanjisi, Public Health Watch researcher and director of
Media Bank, Tanzania 54
National TB programs in Bangladesh, Tanzania, and Thailand have sought to make TB treatment
more accessible and affordable by initiating community-based TB programs, often in
collaboration with NGOs. Though many of these programs have shown impressive results at
relatively low cost, few have attracted sufficient investment and support for scale-up, either
from domestic sources or international donors.
In response to lack of government capacity to administer DOT through health care
workers in every community, BRAC and other NGOs provide community-based TB services
in over two-thirds of Bangladesh. The BRAC approach—the most widely used model of
its kind in the country—revolves around the shastho shebika, or female community health
worker. Shastho shebikas are trained to identify TB symptoms and refer patients to TB diagnostic
centers in the communities in which they live. Once a community member is diagnosed
with TB, shastho shebikas obtain free TB drugs, administer DOT at the household
level, and record and report relevant data to BRAC and to the NTP. Shastho shebikas receive
significant support from BRAC in the form of regular training and refresher courses as
well as the opportunity to earn income: they are permitted to sell pharmaceutical supplies
in their communities, and for each TB patient cured, they receive a small fee of Tk 125
(approximately $1.90). Many reportedly gain personal satisfaction and prestige from their
jobs as well. As one shastho shebika noted in a recent interview, “I enjoy my work because it
has gained me respect in my community.” 55
The BRAC model of community-based care has achieved impressive results: treatment
success rates at or above the global target of 85 percent, 56 at a cost of 50 percent less
than the equivalent services in areas covered by the NTP. 57 BRAC’s community-based DOTS
program has also reaped impressive social dividends. Shastho shebikas distribute information
and raise awareness not only about TB, but about a range of health issues, and not just
to people with TB symptoms, but to the entire community, thus defusing stigma. Shastho
shebikas report that people who have recovered from TB are often their greatest allies in
encouraging others to report symptoms and seek treatment. And the fact that BRAC’s TB
services are implemented in collaboration with the Bangladeshi government, which provides
free drugs, monitoring, and supervision, reinforces governmental capacity and leadership
on TB control.
Pilot community-based DOTS programs have also demonstrated positive treatment
outcomes at relatively low cost in the Kilombero and Temeke districts of Tanzania.
PUBLIC HEALTH WATCH MONITORING REPORTS 25