Community based programmes can help to manage tuberculosis more effectivelyBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7134.864b (Published 14 March 1998) Cite this as: BMJ 1998;316:864
- Richard de Soldenhoff, Regional medical officer
- Sulawesi (Support Programme from the Netherlands Leprosy Relief Association to the Government of Indonesia), Ujung Pandang, Indonesia
EDITOR—In many low income countries the cure rates achieved by tuberculosis field programmes (for sputum smear positive cases) exceed the 85% target set by the World Health Organisation.1 However, the decision to favour outpatient rather than hospital treatment of tuberculosis in many such countries has been influenced by several factors not mentioned in Squire and Wilkinson's editorial2 that were only alluded to in the two accompanying papers. 3 4
Programmes to control tuberculosis are often the responsibility of the divisions for public health, primary healthcare, or control of communicable diseases within the countries' health ministries. Hospitals, particularly at secondary or tertiary referral level (provincial, regional, and university hospitals), usually fall under another division, or even another ministry. Those working in the control programme often have neither the authority nor the status to promote national policy guidelines in these hospitals. This may result in misdiagnosis, idiosyncratic drug regimens, and inadequate documentation and reporting for patients managed by hospitals. In contrast, community centres, clinics, and dispensaries which are directly supervised by—often comparatively junior—programme staff can assume better control and contribute to programme activities in many ways.
The situation in private practice is even more confused. Patients may select only part of the treatment regimen because of the expense involved and may default from treatment after a few weeks, once they start to feel better. Attempts to trace such patients who drop out are rarely undertaken. Cooperation with the control programme—which can help with training, open access to sputum microscopy services, free supplies of drugs, and accompanying monitoring—is essential if there is to be a unified strategy on how to treat the disease.
The national programme incorporating “DOTS” (directly observed treatment, short course) needs to be flexible. In Indonesia, a nominated observer (usually a relative, but it could be a neighbour or influential fellow villager) is briefed carefully and entrusted to be responsible for seeing every home dose taken. This observer can be as effective as a worker based at a health centre. Many patients have their disease diagnosed and documented, receive advice and encouragement, and are started on treatment at a health centre, with their nominated observer in attendance. These patients do not have to go to the district or provincial hospital. We are beginning to see satisfactory cure and completion rates from the rural area. The cities, however, are quite another problem.