Wake up call for community engagement in TB programmes

In Andhra Pradesh state of India, a doctor gulped down sleeping pills when pulled up by authorities for not doing field visits to follow up tuberculosis (TB) patients (source: The Times of India). "There was no other medical officer" in the clinic so she couldn't go to field visits and rather attended to her duties within the clinic – argued the doctor.

India's national TB programme (officially called the Revised National TB Control ProgrammeRNTCP) has incorporated the Patients' Charter for TB Care (The Charter) which is also an integral component of the WHO Stop TB Strategy (2006-2015) at the global level.

The Patients' Charter for TB Care (The Charter) puts forth a rights-and-responsibilities based framework to engage affected communities effectively in TB programmes at all levels, with dignity.

The question is: who has the expertise required to do effective advocacy, communication and social mobilization (ACSM) at the community level? Who can better work on solutions for challenges that confront TB programme outcomes? Are we recognizing, respecting and utilizing the expertise available within affected communities in fighting TB optimally? Are we willing to look beyond a clinical or biomedical response to TB, recognize where the gap lies and engage affected communities with dignity?

The issue of no-doctor-in-clinic is also a sad and disappointing reality – if TB programmes want doctors to do field visits (assuming they can do it better than say the cured TB patients). Engaging communities effectively to play this key role might help.

The question of financial resources shouldn't arise – because doctors have been given resources to do these field visits, which includes a vehicle! "They [doctors] do not go to the field. Hyderabad is the worst performing district in the state. We have given vehicles to these officers, but still they do not go for field work," said Gulzar Natarajan, district collector who had pulled up doctors who were not performing their duties (including the one mentioned above who took sleeping pills) – as per the news published in The Times of India (6 February 2011). Why cannot these existing resources be invested more wisely in engaging communities to get the desired outcome of increased TB case detection and treatment success rate?

Dr KS Sachdeva, Chief Medical Officer (CMO), RNTCP, Central TB Division, Government of India, said in a press conference held in Hyderabad on 24 January 2011: "As we all know, TB is an infectious disease and it is very important for us to detect the TB at the early stages and provide complete treatment. It is seen that most patients do not feel the need to continue the treatment as they feel better of the programme emphasizing for adherence to the treatment and keeping default rate to the minimum with the help of community DOTS provider, majority of the patients enrolled under the programme complete their treatment."

Dr Sachdeva had further informed the media on 24 January 2011 that having achieved the global objectives of 70% case detection and 85% treatment success rate for last three consecutive years, the programme has set for itself an ambitious target of Universal Access to Quality TB Care for all TB patients from whichever healthcare provider they choose to seek care. This calls for reaching out the unreached and fostering an active involvement of private healthcare providers, non-governmental organisations and empowering community to demand for quality TB care services.

Translating 'empowering community to demand for quality TB care services' into reality is a clear mountainous challenge in no uncertain terms. One way forward can be to implement the Patients’ Charter for TB Care in letter and spirit – as genuinely as possible.

Bobby Ramakant - CNS

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  1. Hoosein Kader, Yangon09 February, 2011

    Without knowing the full wordings used during the discussion, we cannot blame the doctor who took sleeping pills when pulled up by authorities for not going to field visits (the doctor said she was the only medical officer in the clinic and couldn't have left the clinic).

    Some wordings are more poisonous than the real poison. On the other hand, the doctor should have chosen other means to explain her burden of clinical duties. May be by counter peaceful discussions. The doctor should not have ever attempted suicide!

    We pray for her recovery, and hope she could continue her services for humanity.

    Warm regards

    Hoosein Kader
    Email: hoosein.kader@gmail.com

  2. Bryan Baleke Ng'ambiChipata09 February, 2011

    It is sad that such a thing happened. This is a lesson to everyone that as we discuss programmatic issues we should endeavour not heap the blame or use unpalatable words or languages at our colleagues. One thing for sure that we should remember is that globally we are faced with a severe shortage of healthcare workers and this calls for levelheadedness in finding solutions to identified problems on the ground.

    The Doctor was right that she could not leave the OPD and go and conduct field visits (this would have entailed burying a hole by digging another). What the team should have done was to look at how best they could have solved challenges on the ground by taking into account the situation at hand and one of the possible ways was to look at task-shifting - engagement of community based volunteers etc.

    For the Doctor, I think she also overreacted, one thing that we should remember is that as we work we should expect to receive diverse views from people concerning our work, views which will either support our work or not. If we feel offended lets engage in constructive dialogue rather the route the Doctor took.

    We will commit her in our prayers and wish her a quick recovery.

    Kind Regards

    Bryan Baleke Ng'ambiChipata
    Email: bryanngambi@ymail.com

  3. The government should find a way they could fill the gap. TASK SHIFTING should be implemented at all costs, and this is where the community should be involved meaningfully.

    It is reasonable that the doctors are given incentive to carry out field activities, but there should be some reason why the doctor did not do the duty of field visit. May be there were patients at the hospital that she was attending to or may be a patient was serious than the one who is in the field.

    TASK SHIFTING should be implemented at all costs, and this is where the community should be involved meaningfully.

    Fred Mwansa
    Email: fredmwansa@yahoo.ca

  4. Dr Shanta Ghatak, India09 February, 2011

    Compassion, kindness, accountability, motivation might not have been equated with competence and performance in a purposeful way. A senior person slighted or reprimanded in person has led to betterment of the program needs in any way?

    Dr Shanta Ghatak, India
    Email: drshantaghatak@gmail.com

  5. Dr P Charles10 February, 2011

    As William Tod Helmuth put it, "Oh, powerful bacillus, With wonder how you fill us, Every day! While medical detectives, With powerful objectives, Watch your play.", TB continues to kill and maim millions of people in their reproductive and productive ages.

    Let's review the human resource for TB control as these if well motivated and then build and strengthen the health delivery of their
    respective communities. The human resource needs to be committed to
    the values/ principles of TB control, adequate in numbers, competent and motivated to provide quality health care services. Short of that as it is worldwide, then lets engage the communities in TB control. Community based programmes are an excellent way of engaging the
    communities to take care of the health.

    Therefore to build a community competent enough to sustain TB control you need the following:

    1) building knowledge and skills of the people including create safe
    social spaces for open dialogue

    2) Promoting ownership and responsibility of their health,

    3) Building confidence in the local strengths, and agency to mobilise these activities,

    4) Building solidarity with communities in TB control, and finally building partnerships at the community and national/ international levels.

    These are similar to the components of Primary health care conceived ages ago!!!

    As Sir William Osler put it, "The desire to take medicine is perhaps
    the greatest feature which distinguishes man from animals" therefore a motivated health workforce will most likely motivate the communities in TB control.

    God bless you all!

    Dr P Charles
    Email: charlespcn@gmail.com

  6. Sad to read of the actions of the doctor when she was singled out by authorities of "neglecting the community programmes" however ,I want to look at it from the angle of the managers, when people are doing support visits, they are supposed to do this with an open mind and should empathize with the situation of that doctor being the only one at the station other than divorcing themselves from reality.

    Technical support visits are not meant for witch hunting.

    All the best to the doctor.

    Stable Besa
    Center for Infectious Disease Research in Zambia (CIDRZ)
    Email: Stable.Besa@cidrz.org

  7. Margaret Gaffney11 February, 2011

    In my opinion the doctor was of course right not to leave the clinic unattended since she was alone and responsible for the clinical work.

    She was obviously under tremendous stress, which was undermining her health and consequently her judgement. Back up for the work was lacking, and "blame" put on her, with the result the clinic was without the medical officer and no field visits done.

    In such cases a human approach is required and with good common sense a plan of action introduced. Suggestion: perhaps a group of volunteers could be trained by the medical worker in the clinic, using some time from her busy schedule to do this programme, taking into account the reality of the situation.


    Margaret Gaffney
    Public Health Nurse
    Email: mvgaffney@gmail.com

  8. Malama Chandalala12 February, 2011

    It is really sad that the doctor decided to overdose herself with sleeping pills. However, it would have been better for her superiors to establish the root cause of her not conducting field visits.

    Upon establishing with the root cause, that is what should have been looked at critically. To start with the managers should have asked this question: 'Why is the Medical Officer working alone at this health institution?' That is something that is supposed to be answered in my view.

    All the best to the Doctor!

    Malama Chandalala
    Emails: chandalalamalama@yahoo.com, chandalalam@carezam.org

  9. It is indeed very sad for the actions taken by the doctor. I have only been a few days in India and have visited a local state hospital. There are very few doctors there and they are working under difficult circumstances and yet, provide a vital health care service. I can just imagine what it must be like working in the more remote areas, virtually operating on your own. Given the challenges it cannot be the most ideal circumstances to work under and yet this doctor too is meeting a vital need of the community supported by the state. I am certain she undertakes her task with diligence. I think too that the action she had taken against herself is sad and, perhaps, a bit drastic.

    However, one has to speak to her and investigate the circumstances preceding her action as, before anyone takes such action, they must surely be at the end of their tether. If one is trying to give off one's best under trying circumstances and then get spoken down to, surely this must be

    I can empathise with her as I can with the huge challenge government also faces. It must be difficult to allocate adequate services all over with limited resources and, often, poor infrastructure. Good health structure exists but it must be supported by the appropriate resources. Perhaps what needs to be done, together with the doctors involved, is to investigate ways in which local communities can be roped in to be care-givers. This model has worked elsewhere and can work here whilst also providing some income in areas where they may be none.


  10. This why we always advocate for more funding to the health sector by our governments in holder to meet the required and healthy centers. Government commitment is the key element to provide the health services. GOVERNMENTS let us drive this with good spirit, and love our countries.


    Fred Mwansa
    Email: fredmwansa@yahoo.ca

  11. Vimla Nadkarni15 February, 2011

    The comment from Dr P Charles is so well-articulated!

    Vimla Nadkarni
    Tata Institute of Social Sciences (TISS)
    Mumbai, India
    Email: vimla@tiss.edu



    I have been reading this string of emails for weeks now, and can no longer sit by, reading with dismay without saying anything. Does nobody else find it bizarre that the main response to this situation has been "oh the poor doctor, we should take pity on her", without looking objectively at the entire situation?

    There is no way for any one of us to know whether or not this doctor was doing her job well or not. There is no way for us to know whether she was over-worked and truly unable to tend to her community-based follow up work, or whether she simply was disinterested in doing so.

    Having worked for quite some time in the Indian healthcare system, I know full well that just like anywhere else in the world, there are some doctors that are terrific, and some that simply are not, with plenty of well-meaning but not-quite-effective doctors in-between.

    Instead of rushing to defend a medical professional whose situation we really have no real knowledge of, perhaps the conversation should be focusing on WHY a doctor was put in charge of community-based TB follow up, when there are literally hundreds, if not thousands, of CBOs throughout the entire country of India. We are talking of a country where the CBO community is so vast and extensive that it boggles the mind how many options are out there to link with. So my question is not about a doctor, my question is this:

    - After literally decades of pouring both international and domestic funding into strengthening the CBO system throughout India to respond to the HIV/AIDS epidemic, why is India's healthcare system not tapping into, and partnering with this vast CBO system, engaging with them as equal partners to fight the spread of TB?

    The Global Fund to fight AIDS, TB and Malaria (GFATM) groups together TB, Malaria and HIV/AIDS for a reason, and since I'm quite sure India has received GFATM money, why isn't anyone making the very obvious connection to partner with HIV/AIDS and Malaria CBOs to do the community-based follow up on TB patients?

    The truth is, I have seen in several places in India, highly successful community-based DOTS programming that is linked to clinics and even care respite centers, that started off as HIV/AIDS service centers but have now expanded their services to be broader and more inclusive of community needs. So again I ask, why is this even an issue to begin with? It seems to me that someone is very much asleep at the wheel.

    We all know full well that silo programming is an inherent problem and obstacle in national programmes in many countries. The heads of HIV/AIDS programming don't necessarily play well with the heads of TB, Malaria or other public health national programmes.

    Carol Rice
    Email: gingerella000@yahoo.com

  13. Oftentimes this is a direct result of bad funding decisions on the part of donors. Other times it is merely ego or some other issue that ends up with the people most in need not getting the vital services that somewhere up the line, have already been funded. I am not saying this is the case in this situation, but these things do happen and we all know this to be true.

    Lastly, since I feel that this is becoming a place where people come to complain but rarely offer suggestions on how to change the issues we all deal with, I would like to conclude this posting with a potential solution for this situation: Starting with the location where this event occurred and expanding statewide and nationally, the country's TB control programme leaders should begin immediate dialogues with local CBOs, to determine how much partnership efforts have already been extended to them, and to either strengthen existing CBO partnerships (identifying promising community-based practices in TB, which I know to already exist), and to establish partnerships between local TB control programming and CBOs in areas where no existing partnership exists.

    Such efforts are not the sole domain of HIV/AIDS or other topic-specific CBOs, and successful community-based TB control activities can indeed be added onto existing CBO work. Follow up of TB patients is not rocket science and it boggles my mind why this conversation is even existing in the year 2011, least of all for a country that has the wealth of CBOs that India has.

    Thank you for allowing me to speak freely within this forum.

    Carol Rice
    Email: gingerella000@yahoo.com

  14. Dr Charles Namisi24 February, 2011

    Whereas the situation is regrettable, we need to protect the profession, just like lawyers do at all cost. A good doctor in my view among other things will protect a colleague. This is entrenched in the Hippocratic oath (original version..."WHILE I CONTINUE to keep this Oath un-violated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!"

    But under this circumstance we are not focused at what led the doctor to overdose herself with sleeping pills. For example could this be suicidal tendencies!

    Let the doctor be reviewed by the psychiatrist, as I feel she may benefit from the consultation.


    Dr Charles Namisi
    Email: charlespcn@gmail.com