Who is in control of TB control?
A multi-sectoral approach to reducing tuberculosis prevalence
Von Jessica Ogden & Mary Hadley
In this presentation we demonstrate the links between poverty and tuberculosis using historical evidence and present experience. We suggest that a multi-sectoral approach has the potential to address root causes of TB related to poverty. Examples are given of three programmes using such an approach and the experiences of these and other similar programmes are outlined. Finally the subject of power is addressed since it is argued that it is the reluctance of health professionals and health policy makers to transfer the necessary power to communities that has been the major constraint to the expansion of such programmes.
Tuberculosis is a disease of poverty. Farmer, in his paper 'The Social Scientist and the New Tuberculosis' argues 'the poor have no option but to be at risk'. Using historical suggestions/evidence and present experience, four ways in which poverty leads to increased tuberculosis prevalence are presented: By increasing the likelihood of disease transmission through over-crowded and poorly ventilated accommodation at home and work; by lowering natural immunity to infection and raising chances of the development of disease through inadequate nutrition and overburden of work; by reducing the ability of the person, once the disease has developed, to seek diagnosis, to commence treatment and to adhere to treatment until cure is achieved; by denying low income families, especially girls, access to basic primary and secondary education.
A multi-sectoral approach to health care addresses these issues and, in doing so, builds on the strong evidence that the benefits to communities of improvements in living conditions and in quality of life can extend to the control of diseases like TB in those communities.
Multi sectoral programmes in practice
The need for a multi-sectoral approach to health was recognised by two doctors working in Jamkkhed, India in the early 1970's. Drs Mabele and Rajanikant Arole became aware that the curative treatment they were providing from a hospital serving a rural community was having no impact on improving the health of the catchment population. Patients were treated, sent back into the impoverished environment and returned at a later date for treatment of another poverty-related disease. This prompted the doctors to initiate a programme that addressed the health needs of the community to compliment the disease treatment approach. While provision of health services was a priority for this programme at the outset, it soon became clear that the community priorities differed. The programme took heed of these 'felt' needs. Communities were supported by the programme in the initiations and execution of strategies to improve agricultural techniques and provide access to safe water as a starting point to meet these needs. Nutritional programmes, both a community and programme priority, were also introduced. Only when these needs had been met did the programme return to its original aim to provide patients with improved access to health care.
In a survey of the health of plantation workers in four developing countries, Laing describes how a number of plantations, using a multi-sectoral approach, improved agricultural techniques, provided access to services such as safe water, sanitation, basic education and health care, improved housing, arranged income-generating activities and established crèches for young children.
Halliman and Williams describe a community development programme in Indonesia which aimed to raise the people's living standard on a broad front by strengthening community institutions, raising income levels through providing assets, capital and vocational skills to the neediest groups and initiating community-based health services of a curative, disease preventative and health promotive nature in all villages. This programme was initiated by a young doctor who had to change his own priority; a voluntary medical scheme, to that of the community's; to raise their meagre incomes, initially through the completion of an irrigation dam.
Examples of areas addressed by the multi sectoral programmes:
- strengthening community institutions
- improving agricultural techniques
- providing access to basic education and health care
- nutritional programmes
- improved housing, including access to safe water and sanitation
- income generating activities
- child care arrangements
In these programmes the change in incidence and prevalence of TB were not recorded. In their place, to describe the outcomes of these programmes, we use proxy indicators: Nutritional status; birth rate and use of family planning and immunisation rates (to demonstrate the increased awareness or basic education of women and/or access to these services); infant mortality rate (known to decline as socio economic status increases and/or more equity in health care access is achieved).
In Jamkhed the nutritional status of children over one year improved so that only 7% children were under the five percentile compared with 22% in control villages, use of family planning increased to 65% of all married couples and a reduction in infant mortality from 150 to 49 infants per 1000 live births was reported.
In the study of plantation workers, results from Zimbabwe indicated the nutritional status of children under five improved and the immunisation rate in this group had risen from 17% to 81% and 91% in two projects adopting these strategies compared with 32% and 59% in non-project plantations. In Sri Lanka, plantations using this strategy reported IMR falling from 74 to 46 per 1000 live births. In India the reported fall was from 119 to 48 per 1000 live births with a corresponding fall in birth rate from 40 to 22 per 1000 population, primarily due to a rise in use of contraceptives from 9% to 49% over a three year period.
In the Indonesian programme the proportion of under 5's gaining weight from the previous month rose from 42.6% to 61.3% over a four year period, high participation rates of family planning were reported and infant mortality fell from 176 to 88 per 1000 live births in a five year period.
Most health programmes are evaluated using these conventional indicators, however, a number of more subtle long term changes have been reported in community based multi sectoral programmes. Examples of other outcomes are:
- health care favouring women from lower socio economic groups
- developing community cohesion and confidence
- increase ability to identify analyse and prioritise their own needs
- more favourable attitudes to low class women health workers
In Jamkhed it was noted that training illiterate or semi-literate married women as village health workers resulted in more women from the lower socio-economic castes coming forward for health care. A marked transformation in attitudes of a whole village community towards low caste women health workers was experienced. In Indonesia peer group pressure stimulated new initiatives and consolidated ongoing work releasing new energies into self reliant paths. At the same time optimum use was made of scarce manpower resources of government and voluntary agencies.
Two further examples derive from other programmes: In Nepal the empowerment of villagers to 'develop community cohesion and confidence, increase their ability to identify, analyse, and prioritise their own needs, and organise the resources to meet these needs' was seen to be the result of a community development programme: In Tanzania in a similar programme it was realised that within a four-year period many village communities had assumed responsibility for the village-based nutritional rehabilitation of their severely malnourished children.
Constraints in the expansion of community based multi-sectoral programmes.
Here the subject of power comes into play. The main constraints are unwillingness of health professionals to participate fully, reluctance to transfer power to communities, political issues, and issues of control
The Jamkhed project reported that unwillingness of health professionals to participate fully prevented further expansion since a good referral system was vital to the success of the programme.
Laing concludes that the difficulty in expanding the multi-sectoral approach to promoting improved health in all plantation settings is that 'developments which enhance the capacity of workers to express themselves are likely to be resisted by employers who depend on a submissive workforce'. He expresses the view that a delicate balance of power between employers and workers must be sought.
Haliman and Williams described the major problems of the programme in Indonesia as being largely political and concerning issues of control. Indeed the notion of TB control i.e. control by 'we experts' puts the power firmly in the hands of health professionals and health policy makers and implementers, wresting it from the community.
It is clear from the examples given that the one major constraint to the expansion of multi-sectoral community based programmes is the relinquishing of power from health professionals to the community. In TB control this reflects in the question: 'Who is in control of TB control?'.
Two key shifts will need to take place within public health to enable these partnerships to develop and to flourish. Firstly, Health sectors and infectious disease control programmes need to join hands with the other key sectors (e.g. agriculture, housing, sanitation and education) and with communities; secondly, infectious disease programmes need to be involved and must be able to maintain the integrity of technical support and funding structures. Within these structures, however, programmes will also need to adopt a broader, longer-term and historically informed view and be willing to share responsibility for disease control with communities and other sectors.
Extract from: Proceedings tb.net 2000; A Conference on Poverty, Power and TB, February 23-25, 2000, Kathmandu, Nepal. Reproduced with the kind permission of the Authors. Contact: Jessica.Ogden@lshtm.ac.uk.
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