mittal shah, kent ranson & palak joshi reaching the poorest: sewa’s experience with tb dots...
TRANSCRIPT
Mittal Shah, Kent Ranson & Palak Joshi
Reaching the poorest: SEWA’s experience with TB DOTS
services
SEWA• SEWA is a trade union of women workers in
the informal economy• Started in 1972 by Ela R. Bhatt• Provides services in Ahmedabad City and
11 rural districts of Gujarat state• Main goals: economic security and self-
reliance• Major activities: organizing, banking and
micro-finance, insurance, capacity-building, health care
• 2003 membership in Gujarat: 4,69,306
SEWA Health• Delivering services since 1980
• Aims to serve the poorest
• Current services delivered:– Preventive: health
education and training, ante-natal care, immunization, occupational and mental health activities
– Curative: low-cost medicines, TB treatment, mobile RCH care, traditional medicines
SEWA’s TB DOTS services
• Since 1999• Partnership with WHO and government• Targets North and East Zones of
Ahmedabad City (population 375,000)• 2003: 1,161 received treatment• 5 stationary centers (each with 2-3
staff) and 11 grassroots DOTS providers
• Regular “area meetings” for demand creation
• Services free of charge
Research Methodology
Phase I Qualitative
Phase II Quantitative
Phase III Qualitative
Research MethodologyObjectives:
• Explore barriers to TB DOTS utilization
• Identify indicators of socio-economic status (SES)
Activities:
• FGDs with TB DOTS users & non-users, including wealth-ranking
• In-depth interviews with service providers & managers
Phase I Qualitative
Research MethodologyObjectives:• Assess SES among TB DOTS users versus
(urban) non-users
Activities:• Exit-survey, >500 respondents• Questions about households assets, utilities,
dwelling and land ownership• Interviewed all service-users over a 4 week
period
Compared to:• Gujarat population, DHS 1998-99, N = 1,709• Ahmedabad population, LSHTM data, 2003, N
= 749• Used wealth index, principal factors analysis
Phase II Quantitative
Research MethodologyObjectives:• Validate findings of previous
phases, with a focus on “Why did the service reach (or fail to reach) the poor?”
Activities:• In-depth interviews with service
providers
Phase III Qualitative
Findings: barriers to utilizationDemand• Fear of discrimination• Some perceive quality to be low• Personal events: e.g. weddings, funerals• Migrant laborers can not attend regularly• Alcohol addicted patients fail to complySupply• Side-effects result in drop-outs• Special support required for dealing with
alcohol addicted pts (or others with compliance problems, like migrants)
If the woman had TB, she would be sent away from her husband’s house, to her mother’s house! Her husband’s family would refuse to keep her in the house. So some women would not come, thinking about all this.
Interview with SEWA Health grassroots worker
Findings: barriers to utilization
If their in-law’s house is nearby then they are afraid that their engagement will be cancelled because of the disease… In one case, when we went to the patient’s house they did not like it at all. The next day the girl’s father called up to say angrily that no one should come to my house... her in-laws house is nearby.
Interview with SEWA Health grassroots worker
Findings: barriers to utilization
• 663 TB DOTS users interviewed
• Of those interviewed (N = 663), 62% were men and 38% women
Findings
Findings: Top 5 indicators of SES (DHS, urban Gujarat, 1998-99)
Frequency
Rank VariableDHS
(N = 1,709)TB DOTS (N = 663)
1 If electricity lighting 94.1% 91.1%
2 If biogas cooking fuel 0.1% 0.0%
3 If gas cooking fuel 57.0% 33.8%
4 If kaccha house 5.3% 13.6%
5 If no toilet facility 23.1% 6.8%
Findings: Percentage distribution of urban SEWA Health service users by SES quintile
(compared to DHS 1998-99)
Findings: Concentration curve, urban SEWA Health service (compared to DHS 1998-99)
0
0.2
0.4
0.6
0.8
1
1.2
0 1 2 3 4 5
Quintile
Se
rvic
e u
tili
zati
on TB DOTS
0
0.2
0.4
0.6
0.8
1
1.2
0 1 2 3 4 5
Quintile
Se
rvic
e u
tili
zati
on
RH Camps
Women’s training
TB DOTS
Findings: Concentration curve, urban SEWA Health service (compared to DHS 1998-99)
Findings: Percentage distribution of urban SEWA Health service users by SES quintile
(compared to LSHTM 2003)
Findings: Concentration curve, urban SEWA Health service (compared to LSHTM 2003)
0
0.2
0.4
0.6
0.8
1
1.2
0 1 2 3 4 5
Quintile
Se
rvic
e u
tili
zati
on
TB DOTS
Findings: Concentration curve, urban SEWA Health service (compared to LSHTM 2003)
0
0.2
0.4
0.6
0.8
1
1.2
0 1 2 3 4 5
Quintile
Se
rvic
e u
tili
zati
on
TB DOTS
RH Camps
Women’s training
• SEWA Health’s TB DOTS services reach the poor: 69% of users from lowest 2 SES quintiles
• RH Mobile Camps slightly more successful in reaching the poor
• Substantial barriers to use by women
Policy implications: summary of findings
Why are SEWA Health’s TB DOTS services successful in reaching the poor?
• Delivered to the “doorstep” in high-density urban areas
• Convenient timings• Run by poor, local women and their own
organization (cooperative)• Combined with efforts to educate and
mobilize the community• Trust in SEWA• Free of cost
How can SEWA Health’s TB DOTS services better reach the poor?
• Address the barriers faced by women– Educate households that TB is curable– Experience-sharing by women who have been cured
• Develop special supports for alcohol addicted patients– Involvement of family and community in treatment
• Improve education about, and treatment of, side-effects
• More trained peripheral DOTS workers to provide to those who live far from centres