February 2002 Insights
Health Issue #2
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DOTS on the spot
Lessons for access to HIV care
People with HIV/AIDS
in developing countries become stigmatised and impoverished by their
disease. How can health systems deliver effective care to the most vulnerable
people? Tuberculosis (TB) is another impoverishing disease requiring
complex long-term care. What can we learn from a well-functioning DOTS
programme for TB (see box)?
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What's
DOTS?
In Malawi, the WHO's directly-observed treatment, short-course
(DOTS) strategy for TB treatment has been implemented for two
decades and consists of:
- diagnosis
in the general health service, using sputum microscopy
- standardised
short-course drug treatment (minimum eight months) supervised
primarily at health facilities but increasingly also in the
home
- regular
uninterrupted drug supplies
- accurate
record-keeping, supervision and programme evaluation
- government
commitment to TB control.
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The TB Equity Project
(developed by the Malawi National TB Programme and the Liverpool School
of Tropical Medicine) investigated whether TB treatment is accessible
to poor and vulnerable Malawians. The research included focus groups,
semi-structured and in-depth interviews, a patient survey, operational
research and mapping of health facility usage and TB cases against indicators
of poverty. It identified significant barriers to access to TB care
and ways to tackle these problems (see figure).
It also showed that:
- The poor have
the highest burden of illness and the least access to TB services.
- People with
TB seek care from various sources, including shops and private and
traditional practitioners.
- Diagnostic procedures
have developed around specific tests for infectious cases rather than
patients' needs. Patients have to visit the hospital many times for
diagnosis (consultation, laboratory tests, X-rays) and supervision
of treatment.
The research has
implications for each component of a comprehensive care package for
HIV/AIDS:
Care for HIV-related
infections (including TB) - train community health workers to treat
infections based on their symptoms, even if HIV tests are unavailable
Voluntary counselling
and testing - provide resources for services which are close to
communities, backed up by laboratory quality assurance
Care and support
within the community - involve private practitioners from the formal
and traditional sectors
Antiretroviral
drugs - engage patients and communities in the design, implementation
and monitoring of services.
Even within a well-functioning
DOTS programme such as this one, poor and vulnerable TB patients can
be lost or missed altogether. To ensure equity in access, TB services
must be patient-centred. The same principles will apply to the provision
of care for HIV/AIDS.
Bertie Squire,
Felix Salaniponi and Julia Kemp
Liverpool School of Tropical Medicine
Liverpool L3 5QA
UK
T +44 (0)151 708
9393
F +44 (0)151 707 9193
sbsquire@liv.ac.uk
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