The World Health Organisation (WHO) estimates that only 32 percent of the world’s population has access to DOTS – a TB treatment strategy that requires health workers to watch patients taking their drugs. How can policy-makers improve the availability of DOTS? Community health workers may provide a cost-effective solution.

TB is a major health problem in Bangladesh. There are two major TB control programmes in the country: one run by the Bangladesh Rural Advancement Committee (BRAC); the other managed by the government. The programmes use the same DOTS strategy, but BRAC relies mainly on community health workers to observe treatment, while the government provides treatment mostly through thana (sub-district) health centres. A study by BRAC and their research partners compared the cost-effectiveness of the two programmes.

Results included:

• In the BRAC and government areas, respectively, a total of 186 and 185 patients were identified over one year.
• The overall treatment success rates were 83.3 and 82.7 percent.
• Ten percent of patients in the BRAC programme died; the figure was 12 percent in the government programme.
• The cost per patient cured was US$ 64 under BRAC and US$ 96 in the government programme.
• Salaries and drugs together accounted for 77 and 83 percent of total spending in each programme. Drug costs were similar for both, but salary costs under BRAC were only 43 percent of those in the national TB programme.

The researchers discuss alternative strategies for improving access to DOTS:

• Keeping patients in hospitals for long stays would increase the burden on patients and hospitals in developing countries. Also, there would not be enough hospital beds for all patients.
• There are also problems in promoting DOTS through outpatient clinics, as health services are not accessible in many rural areas.

The BRAC model provides care for TB patients based on community participation. Patients and community health workers live in the same village so patient costs are reduced. Although both the BRAC and government programmes achieve satisfactory cure rates, the involvement of community health workers improves cost-effectiveness. However, the researchers point out that population density, health service infrastructure, drug prices and the general economic conditions in a country also influence programme costs. They recommend that government health services should collaborate with non-governmental organisations to mobilise community health workers for TB control.

Source(s):
‘Cost-effectiveness of community health workers in tuberculosis control in Bangladesh’, Bulletin of the World Health Organisation 80 (6): 445-450, by M. Islam, S. Wakai, N. Ishikawa, A. Chowdhury and J. Vaughan, 2002 Full document.

Funded by: Sasakawa Health Science Foundation, Japan; Research Institute of Tuberculosis, Japan; Bangladesh Committee for Rural Advancement

id21 Research Highlight: 5 September 2002

Further Information:
Susumu Wakai
Professor and Chairman
Department of International Community Health
Graduate School of Medicine
University of Tokyo
7-3-1 Hongo
Bunkyo-ku
Tokyo 113-0033
Japan

Tel: +81 35841 3698
Fax: +81 35841 3422
Contact the contributor: swakai@m.u-tokyo.ac.jp

World Health Organisation

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