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Keywords:

  • TB;
  • poverty;
  • vulnerability;
  • direct observation of treatment

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The Revised National Tuberculosis Control Programme (RNTCP), based on the World Health Organization's DOTS strategy,* was introduced in India in the mid-1990s. This paper reports the findings from operational research studies in two pilot sites in New Delhi from 1996 to 1998. A variety of operational research methods were used, including semi-structured interviews, focus group discussions, non-participant observations and collection of data from the tuberculosis registers. The cure rates for the clinics were 71 and 75% with a default rate of 6 and 11%, respectively. An important finding was that health workers screened patients to determine their ability to conform to the direct observation of treatment element of the RNTCP. If the health worker was confident that the patient would comply and/or be easy to trace in the community in the event of `default', they were provided with short-course treatment under the RNTCP. Other patients, largely those who were in absolute poverty, socially marginalized, itinerant labourers, poorly integrated in the city, were put on standard tuberculosis (TB) treatment as for the previous National TB Programme. The programme was evidently excluding the most vulnerable from the best available care. These findings demonstrate the potential dangers of target-driven programmes where there is an absence of support to both frontline health workers and patients. The paper also highlights the importance of operations research in helping to identify problems within TB programmes.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Despite a well-designed National Tuberculosis Programme (NTP) developed in the 1960s, tuberculosis (TB) continues to be a major health problem in India (WHO 1997). An expert review of the National Programme undertaken by the Indian Government along with the World Health Organization (WHO) and the Swedish International Development Agency in 1992 found that less than 30% of patients enrolled under the programme completed treatment (WHO 1992). The major reasons identified for the poor completion rates included frequent shortages of drugs, inadequate staff and budgets, poor diagnostic tools as well as poor patient follow-up. On the basis of these findings the NTP was revised, bringing it in line with the international strategy known as `DOTS', directly observed therapy short course (Revised National TB Control Programme (RNTCP), Government of India 1997a). The WHO DOTS strategy, which was introduced in 1993, is the cornerstone policy for tuberculosis control internationally and it has been introduced into the TB control programme in a variety of countries with great success. There have, however, been controversies about the `directly observed therapy' component of the strategy (WHO 1999).

The Revised National Tuberculosis Control Programme of India (RNTCP) was launched in 1993 as a pilot project, with a loan from the World Bank and further assistance from the UK's Department for International Development (DFID) (Khatri & Frieden 2000). The objective of the revised strategy is to reduce the burden of tuberculosis in India through improved diagnosis and treatment supported by political commitment, regular drug supply and `rigorous monitoring of treatment outcomes' (Khatri & Frieden 2000). The keystones of the programme were the targets of 85% cure and 70% coverage. The strategy was designed to overcome shortcomings of the previous national programme and includes the following organizational principles: availability of a decentralized diagnostic and treatment network integrated with Primary Health Care; sound programme management based on accountability and supervision of health care workers; and in-built evaluation of treatment outcomes (RNTCP, Government of India 1997b). Directly observed treatment (DOT), in which a trained health worker supervises the swallowing of drugs, is a key element of the strategy (RNTCP, Government of India 1997b), intended to prevent emergence of resistance to drugs in the short-course regimens (WHO 1999).

In 1996, the DFID Health and Population office in New Delhi initiated a programme of substantive `Operational Research' to assess the acceptability and feasibility of the RNTCP in the field. The objectives of the operational research projects were to study the functioning of the RNTCP in the three pilot sites they were supporting, two in New Delhi and the District of Medak in Andhra Pradesh. The DFID was interested in assessing acceptance of the revised strategy by health functionaries, patients, their families and their communities. In addition, it was felt that a formative evaluation of the strategy, its organization and management was needed during this early period to ensure sustainability and acceptability through the scaling up process.

This paper reports findings from the studies carried out in the New Delhi pilot sites by the Lala Ram Sarup Institute of Tuberculosis and Allied Diseases with the support of the Foundation for Research in Community Health, Mumbai, and the London School of Hygiene & Tropical Medicine (Department for International Development (DFID) 1998). The objectives of the research were to conduct a short-term evaluation of the pilot sites to determine the effect of the introduction of the RNTCP into the NTP, the problems identified by staff and patients, and to suggest potential strategies to deal with the problems to produce a system that is appropriate for staff and humane and equitable for patients.

Background

The RNTCP pilot projects, developed to assess the technical soundness and operational feasibility of the strategy, ran in a number of urban and rural areas across the country. Initial population coverage was 2.35 million, later expanding to 13.85 million. The outcome of the pilot work was promising: diagnostic practices improved with effective use of quality sputum microscopy and cure rates doubled. Because of these encouraging results the RNTCP is now being extended in a phased manner to 102 districts covering a population of 271.2 million (Khatri & Frieden 2000). In 2001, the programme covered a population of 420 million with more than 700 000 patients having been treated under the RNTCP (Central TB Division Delhi 2001).

Study sites

This study was conducted in two chest clinics in the National Capital Territory of Delhi. Nehru Nagar Chest Clinic (NNCC) is situated in the south of Delhi and Moti Nagar chest clinic (MNCC) in the west. The study areas have urban, peri-urban and rural populations, having representation from all socio-economic strata. A large number of economic migrant and slum populations also live in this area. The total area under the care of these two centres occupies between 25 and 30% of the entire area of Delhi. These clinics are typical of the TB treatment organized in urban settings of major cities and metropolitan areas like Delhi. Moti Nagar clinic introduced the RNTCP in June 1996. It had 11 DOT centres and these were all functioning by March 1997. The clinic covers a population of 1.1 million. The staff in the clinic consisted of: one project officer, two assistant project officers, two Senior Treatment Supervisors, 13 TB Health Visitors, one laboratory technician, and three laboratory assistants. Nehru Nagar clinic introduced the RNTCP in January 1996 and had 14 DOT centres. All were functioning by January 1997. It covered a population of 1.4 million. The staff consisted of: one project officer, three assistant project officers, two Senior Treatment Supervisors, 15 TB Health Visitors, one laboratory technician, and one laboratory assistant. The 25 peripheral DOT outreach units (DOT centres) in the community are located in dispensaries run by various government agencies, except in places where no such facilities exist. A trained TB worker runs each of these centres, supervises treatment and helps to maintain registers. In two centres, where the patient load was high, the TB Health Visitor was assisted by Community Health Volunteers. At the time some distant peri-urban and rural pockets in the designated area were not covered under the DOTS strategy.

The microscopic facilities for sputum testing are centralized at the main chest clinic in each area and covered a population of approximately 300 000. Each DOT centre, designed to support a population of around 100 000, is open to the public and TB patients from the chest clinics are referred here after diagnosis. It is estimated with the current incidence of TB that about 125 patients would be diagnosed for every 100 000 population at each DOT centre. At the centres, the patients are to be educated about tuberculosis and also motivated for treatment as these centres are also the nodal points for delivering observed therapy.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The aim of the operational research was to assess the needs and perspectives of RNTCP patients and providers in the two chest clinic areas. The objectives of the work were `to more fully understand the social, cultural and economic factors that influence treatment seeking for TB symptoms so that recommendations can be made for more effective and appropriate delivery of services under the RNTCP' (DFID 1998). The project employed a `qualitative approach' (Ogden & Porter 1999), using a range of quantitative and qualitative methods. The methodology presupposes that key programme questions of `access' and `adherence' can best be answered by interrogating factors in four overlapping domains: Programme/Policy, Community/Household, Patient, Health Services/Provision. Figure 1 illustrates these domains and the methods employed in each (e.g. mapping, semi-structured interviews; focus group discussions; non-participant observation). In this paper, we focus primarily on data collected through semi-structured interviews with 59 DOT centre patients who were not on the RNTCP and interviews with 21 TB Health Visitors. Findings from non-participant observations conducted in the DOT centres, records review and community mapping are also presented. Non-participant observation addressed four major areas: the infrastructure of the centre, the work of the TB health visitor, the flow of patients through the centre, and the way the health provider dealt with the logistics of programme requirements.

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Figure 1. Methods and methodology of the research.

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Ethical permission for the study was received from the ethics committees at the Lala Ram Sarup Institute and the London School of Hygiene and Tropical Medicine.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Staff patterns and patient flow

The process of entry into the TB programme begins when a person with indicative symptoms first reports to one of the chest clinics. These patients then undergo sputum examination and chest X-ray (where indicated) (RNTCP, Government of India 1997b). Those diagnosed as having TB are then classified as `area' or `non-area' cases, depending on whether they reside in or outside the clinic catchment area. RNTCP (short-course) regimens are offered to `area' patients (those residing within the clinic jurisdiction) only. `Non-area' patients are either sent to their own local chest clinic or offered standard chemotherapy (12–18 month unsupervised regimes). Thus, the chest clinics under study were clearly operating parallel treatment systems: chest-clinic based unsupervised standard treatment (NTP) for non-area patients, and DOT-centre based, observed short-course chemotherapy (RNTCP) for area patients. The stringent monitoring and evaluation of cure rates and treatment outcomes is conducted only for RNTCP patients whereas NTP or standard treatment patients are reported separately as before.

After a positive diagnosis of pulmonary TB is made and the patient is categorized, a Treatment Card and Patient Identity Card are prepared and the patient is registered with the clinic. The doctor explains the treatment schedule and refers the patient to the area treatment centre for DOT. The TB Health Visitor visits the home of the patient, and speaks with the patient and his or her family, emphasizing the importance of adhering to the treatment schedule. The patient is then requested to come to the treatment/microscopy centre at a convenient location three times per week to receive drugs under direct observation during the intensive phase. The TB Health Visitor monitors the therapy, manages drug reactions and takes `defaulter retrieval action' – i.e., should the patient fail to appear for DOT on more than two occasions, the health visitor must go back to the patient's home and bring them in for treatment – an often time-consuming and difficult task, particularly in the very low-income `slum' areas in which many patients live.

During the study it was observed that there was a clear division between the practices of the staff employed by the clinic and those designated for the RNTCP work in the clinic. Any patient who was diagnosed with TB by the doctor was referred to the TB Health Visitor or DOT worker who discussed the schedule with the patient, assessed the feasibility of providing `observed treatment' before offering to register the patient for supervised treatment. The TB Health Visitor had the final authority to decide enrolment. Those patients not considered suitable for DOT were sent back to the clinic staff for unsupervised treatment.

The average number of patients visiting DOT centres was 40 per day, with two of the centres having larger patient loads. At centres where the number of patients exceeded 100, an additional community volunteer was provided.

Almost all centres opened by 9 AM and there tended to be a rush of patients in the early hours because many patients wanted to take their medicines before going to work. Therefore, in the first hour, it was practically impossible for a TB Health Visitor to administer the drugs under direct observation, and most patients at this time of day were handed their drugs and asked to take them in another part of the centre to allow for speedier patient flow. The rush of patients also denied the opportunity for any communication or casual conversation between the patients and the DOT provider.

Treatment outcomes and patient enrolment

The treatment outcome reports of the two clinics were evaluated. At the time of our study, the MNCC had reported treatment outcomes to the third quarter of 1996. They reported a cure rate of 71% among 99 new smear positive patients registered and fully treated at this facility. The default rate was about 6%. The cure rate reported by the NNCC was 75% for the 275 new smear positive patients for whom final results were available. They reported a default rate of 11%. If the proportion of cases that completed their treatment is added the `success rate' exceeds 80%.

Chest clinic records were screened for patient enrolment in the second quarter (April, May and June) of 1997. A total of 1786 and 1890 patients were on treatment under RNTCP at Moti Nagar and Nehru Nagar clinics, respectively, at the time of data collection (September 1997). These findings are summarized in Table 1.

Table 1.  Area patient enrolment in RNTCP and NTP in Moti Nagar and Nehru Nagar Districts (second quarter 1997) Thumbnail image of

In Moti Nagar, 489 patients (313, 64% male; 176, 36% female) had been put on `direct observation of treatment' as per the RNTCP and 842 on the NTP non-supervised treatment. Of the 842 patients who were not given DOT, 495 were males (59%) and 347 females (41%). In the NNCC, 409 (245, 60% male; 164, 40% female) had been placed on DOT and 422 (287, 68% male; 135, 32% female) on the non-supervised regimens.

The programme guidelines state that all individuals presenting to the clinics for diagnosis, who are diagnosed as having TB, should be placed on the RNTCP for treatment and entered into the registers. Thus, the apparent non-registration of an important number of patients (63% in Moti Nagar and 51% in Nehru Nagar) called for further investigation. The remainder of this paper explores the questions around the non-enrolment of patients onto the RNTCP. Patient, provider and broader socio-economic factors emerge and these are explored in turn below.

Non-enrolment of patients: patient issues

Fifty-nine patients were interviewed who had either refused or were denied directly observed therapy with the short-course regimen. There were nearly equal proportions of men and women in the selected groups (M:F, 31:28), and most patients (38/59, 64%) were between 16 and 35 years of age. Of these patients, 41 were denied enrolment by the TB care system. The remaining 18 refused on their own as they were not sure about their ability to conform to the DOT schedule. The following reasons were given by the TB patients for `refusing DOT': 12 indicated that the nature of their work or timing of their job or school was not suitable for DOT visits; two were apprehensive of the new DOT system; two were `too sick to walk to the centre every other day'; one stated that repeated visits to the centre would identify him as a TB patient; and one was a migrant and unable to go back to the centre.

The most important reason given by patients for not accepting treatment under the RNTCP was logistical: they did not feel they could manage to meet the requirement for alternate day attendance at the DOT centre given the competing priorities and demands of their daily lives. It was perceived particularly difficult for those patients engaged in daily wage labour and for children still in school.

Provider issues

The DOT workers as well as their supervisors indicated that all the patients reporting to their units do have to undergo an interview to identify those who are not likely to complete treatment as `they could not afford to spoil our results by registering patients who are less able to complete their treatment.' The patient characteristics hampering completion of tuberculosis treatment were identified as some or all of the following factors: social marginalization (abandoned or widowed mothers, alcoholics, poor, low caste); low level of integration in the city (new migrants, some women – especially newly married women from the villages who have come to their natal homes because of sickness); absolute poverty; past history of irregular treatment; itinerant labouring and some types of wage labouring which require regular trips out of the area. Thus, those denied treatment could be classified as among the most poor and socially marginalized – people who are also unlikely to be able to afford private sector treatment. As a supervisor in the centre remarked: `The migrants from some of these states (i.e. the poorest) can be least trusted.'

The 41 patients who were denied enrolment after interview with the TB Health Visitor stated the following reasons which made them `a suspect' in the eyes of `the system.' Fourteen of these patients had no proof of permanent or bona fide residence in Delhi (e.g. they had no ration card or were recent migrants to the area). Nineteen patients were precluded as they had social factors which could affect their regular visit to the DOT centre (highly mobile jobs, odd working hours or deemed likely to leave the area). Four patients were found unsuitable as they were too sick or lived too far away from the DOT centre. Another four patients were not enrolled because they had a history of irregular treatment in the past (previous default which was deemed a risk factor for future default).

A DOT worker in one clinic approached the problem in this way: she starts a patient on treatment and if, after a few `test doses', the patient experiences problems or does not come regularly for DOT, the health visitor discontinues the treatment. The patient is recorded as one who refused DOT. No further reference need be made to this patient. The TB treatment card is removed from the centre and so no record exists of this `enrolment.' In other words, the patient is not recorded as a `defaulter' and the clinic records (and therefore `results') remain unaffected.

Thus, the health workers in the DOT centres developed a means for identifying those patients they suspected would not adhere to treatment. In effect these providers ran each patient through an adherence algorithm. Table 2 was constructed from the data collected from interviews with patients and providers and from the non-participant observation in the clinics.

Table 2.  Entry algorithm for TB patients to be registered on the RNTCP Thumbnail image of

Social/economic issues

The story below highlights the problem of seeking TB treatment from within an impoverished community.

… `T', a 40-year-old pulmonary TB patient, had come from Uttar Pradesh with his son 1 year ago to earn some money by working within the Moti Nagar area. He lives by making cardboard boxes and earns Rupees 1500 (approximately $30) per month. He has a family of four to support in the village and sends his monthly savings to the village. For the past 2–3 months he has been ill with fever and cough. He visited a private doctor who diagnosed him by X-ray as suffering from pulmonary TB and referred him to the MNCC where he was found to be sputum positive. DOTS was explained to him by the medical officer and he agreed to have observed treatment. He was then referred to his nearest DOT centre for treatment. When the DOT worker met him, however, he identified several `risk factors': T is a recent migrant, living in rented accommodation, without a ration card. His family was also in the village and it was assumed that he would need to go back from time to time. He was therefore refused DOT. The patient, having had his hopes raised with the promise of short-course chemotherapy, promised not to leave the city until his treatment was completed, but he was refused, and placed on the standard regimen.

The urban slums of Delhi have a large proportion of migrant or temporary settlers in search of better job opportunities. There are also those who come temporarily in order to get treatment at the higher quality, free public institutions in the capital. This mobile population is difficult to treat for TB, as many will return to their native places after some time. According to our respondents, permanently settled residents of the area are more likely to be able to comply with the rigours of the RNTCP system, and these are the patients normally selected for the RNTCP/DOTS. Those identified as mobile are perceived as likely to default, and these patients are generally placed on standard, unsupervised treatment. The most common method for verifying mobility is to ask all patients to produce a ration card. So prevalent is this norm that many in the community will only visit the chest clinic if they have a ration card. We came across a person who, after being told that he was suffering from TB and should go to the area chest clinic, did not do so for more than a month until he managed to have a ration card made. This, however, put the relatively permanent but poor settlers like those living in rented accommodation or squatter settlements at a disadvantage as they were often not permitted by their landlords to get ration cards made. A second means for assessing the risk of defaulting from treatment is whether or not the patient has a regular job or family in the city. Those patients who can provide neither a ration card nor evidence of regular employment will be asked to find someone from the community to guarantee their completion of treatment. The following excerpt from a patient case study reveals the challenges this system poses to the poor.

`S' has been staying in a Delhi slum for the last 10–12 years with her four children and husband who is a daily-wage earner. She had cough, fever and haemoptysis and was diagnosed with pulmonary TB at Moti Nagar. She was asked to produce her ration card but she had none, as her landlord has not allowed her to get one made. On her insistence the DOT worker decided to enrol her and visited her house. Her landlord subsequently came to know about her disease and evicted her. She had to find another place to live, and when the DOT worker discovered this he sensed she might continue to shift residence and therefore become difficult to trace. She was consequently switched to standard treatment. `S', however, persisted with her demands for DOTS. The DOT worker, with the support of his senior treatment supervisor, told her that he could risk giving her DOTS provided a `big' person from the community would guarantee that she completed her treatment. `S' tried but could not secure a guarantor. Again she was denied care under the RNTCP. `S' remained emphatic that she be given short-course treatment, telling us, `I have to live for my children. I shall stay on rent at a place close to the DOT centre even if it costs me more but I must get the best treatment.' The issue remained unresolved.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The results of this operations research highlight the difficulties faced by both patients and frontline providers in implementing a TB control strategy focused around DOT and the achievement of particular `targets.' The findings suggest that, as it operated during our research, the RNTCP programme in Delhi was not geared up to meet the TB care needs of the potentially most vulnerable patients. The work is historical in that it took place during a particular time in the implementation of the RNTCP in India and attempts have been, and are continuing to me made to correct these problems. Nevertheless, it identifies important effects of the interaction between the health system (health care provider), the community (patient), the programme, and national and international TB control policy. Some of these issues are also discussed by Balasubramanian et al. (2000) in a study from Kerala which noted that more than one-fourth of patients in the RNTCP did not receive treatment under observation because of issues of age/infirmity and fear of social stigma (Balasubramanian et al. 2000). Through a better understanding of these dynamics, programmes have the opportunity of not only improving their `cure rates', but more importantly improving the `care' of patients and thus the health and dignity of both the patient and the provider.

Information from the Indian Ministry of Health indicates the scale and success of the RNTCP (Central TB Division Delhi 2001). Within this success, however, it is important to highlight the problems encountered in implementing the strategy. The research reported here indicates the value of operations research in identifying these problems, as well as possible solutions to them. The research findings provide an opportunity to reflect on current practice and to find creative ways of addressing the problems identified. Although situated in India, this work has important messages for TB control programmes in many other countries.

An RNTCP programme manager would not necessarily notice a `problem' when assessing the data emerging from these clinics through their records: the cure rates of these clinics were reasonably good and the defaulter rates quite low. Our data indicate, however, that these figures mask another story. From a TB control point of view it could be argued that the problem identified is one of `coverage': contrary to programme guidelines, not all patients presenting to the clinics are being put on the RNTCP and given access to the best available TB treatment and care. Indeed, more than half of all presenting patients are either opting out of or being refused access to DOTS by the frontline health workers. Thus, most appropriately diagnosed tuberculosis patients (many of them sputum positive) presenting to these clinics for treatment are being sent back into their communities with suboptimal care. The impact of this on transmission of TB in the community is not known, but the implications are worrying.

In terms of TB control this situation is problematic in and of itself. However, there is a further issue highlighted by our research, which is about social vulnerability. Of those patients who either refused or were denied RNTCP treatment, most could be classified as among the poorest and most socially marginalized in the community. These are largely people deemed unable to comply with directly observed short-course chemotherapy because they are very poor, with unstable jobs and/or residence, with few social networks in the city to fall back on for support, and/or who are very sick. Many of these patients were sincere in their desire for RNTCP treatment, and were committed to getting well as quickly as possible, but were being thwarted in their efforts by a programme which classified them as likely to default. Clearly, the programme has a responsibility to these patients no less than those who are relatively better off and/or living in less socially and economically precarious conditions. These findings are important because the patients who have been left out of treatment are the patients who commonly cannot afford treatment in the private sector. If DOTS is the mark of quality care, then a significant subset of deserving and willing patients were denied the best opportunity to be cured. Equity is important in public health programmes and it is important to ensure that human rights are not being sacrificed on the altar of the nationally and internationally approved target cure rates.

The reasons for this unfortunate outcome can be best understood as stemming from the interactions between the programme, the frontline providers and the patients. Clearly, the RNTCP/DOTS relies heavily for its success upon the TB Health Visitor. These providers are the linchpins of the programme, the essential link between the programme and the patients it has been designed to help. They are responsible for maintaining the registers, for delivering short-course treatment under direct observation, for following up patients and for defaulter retrieval. Assuming all the other aspects of DOTS are in place, it is finally up to this cadre of health worker to achieve the targets set, not only at national, but at an international level as well. Therefore, in the absence of adequate support these pivotal programme staff developed a coping strategy which while possibly maintaining the cure rates (and therefore programme goals), in fact work against TB control principles by failing to avail the best available therapy to infectious TB patients. These workers were evidently working from a project or programme orientation, rather than a TB-control orientation. Their focus was on cure rates, rather than curing patients.

The `entry' algorithm developed by the TB Health Visitors in Delhi provides a useful basis for understanding more about the lives of the patients and the factors in their lives which may impede their ability to complete a full course of anti-TB treatment. Currently, these are glossed over as `risk factors for default.' Looking at the same factors from a different point of view (one that does not have targets and cure rates at its foundation), they could also act as `indicators of need.' The very same algorithm used to exclude vulnerable patients could as well be used to identify those most in need of extra care and support. As we have argued elsewhere (Ogden 2000), `refocusing public health around a notion of care and support should support a process whereby the needs of public health and the needs of patients are both satisfied.. The research findings point to simple interventions that would improve the link between patients and providers. For example, more extensive/flexible hours of operation and neighbourhood DOT to meet the unmet demand in the community. These issues are being addressed with the RNTCP and are also being initiated in the revised DOTS strategy from WHO which is described as a `comprehensive support strategy – support to all providers, patients and people to tackle the problem of TB' (www.stoptb.org/material/revised_framework.intro.htm).

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We thank Dr Mukund Uplekar, Dr Sheela Rangan, Dr Morankar, and Sanjay Juvekar at the Foundation for Research in Community Health, Mumbai, for their considerable work on this project. The work was funded by the UK DFID.

Footnotes
  1. *DOTS is the brand name (not an acronym) given to the current international strategy for TB control endorsed by the World Health Organisation and the International Union Against Tuberculosis and Lung Disease. For an overview of the strategy see www.who.int/gtb/dots/index.htm

  2. These cards are provided by the government to purchase provisions at subsidized price. The cards are now used for many official purposes particularly to identify bona fide settlers for re-housing under government schemes. These cards are highly valuable to city dwellers, and often the more recent or new settlers do not have them.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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