presented by: dr. a n zafar ullaha n zafar ullah nuffield centre for international health and...

Directorate General of Health Services Ministry of Health & Family Welfare

Nuffield Centre for International Health And Development, University of Leeds, UK



Presented by: Dr. A N Zafar Ullah

Nuffield Centre for International Health and Development, University of Leeds, United Kingdom.

E-mail: [email protected]

[Based on the paper being published in the INT J TUBERC LUNG DIS]

mailto:[email protected]



Presentation Focus

1. Process of developing the partnership model

2. Its impact on Tuberculosis control outcomes

3. Policy Implications



• Population:140 million

• High TB Burden:

– Ranked 5th in TB amongst 22 High Burden Countries

– 320,000 new TB cases/year

– 64,000 die annually

• Garment sector is large and growing and major contributor to the economy:

– More than 5,000 big and medium sized factories

– Employing 3.6 million workers



Background Context (2) • Most garment factories are located

in Dhaka city or adjoining areas

• Majority of these factories are working for multinational, branded companies.

• Around 90% of garment workers are:

– Young female

– Poor

– Migrated from rural

– Long working hours

• Health care provision in the workplace (garment) is negligible.



Aim and objectives The overall aim of this project is to develop an effective, sustainable TB control programme in the garment sector in Bangladesh.

Specific Objectives are to:

• Understand the context , in particular, the current service provision of TB care in the garment sector in Bangladesh;

• Develop a model to engage the selected garment factories in TB control activities;

• Develop protocols, guides and tools for workplace TB control;

• Assess the effectiveness of the mechanism in terms of TB outcomes.



Study Design

Study Areas:

3 sites in Dhaka city were selected purposively:

• Mirpur: NTP and PSKP

• Rampura: NTP and PSTC

• Dokkhinkhan: NTP and BRAC

Selection criteria:

• Hub of garment factories

• SEED, NTP and NGOs are having joint TB control programme

• Linkage with PPP TB project

• BGMEA’s health centres

• Operations research; embedded within the national TB control programme (NTP)

Develop Test Evaluate Scale up



Sampling and data collection

• Multi-stage sampling frame: BGMEA-member factories in three areas (N=170 ) Questionnaire survey. Interested? YES/NO (n=60; total

workers= 69,000) Baseline information: Questionnaire survey, In-depth

interviews, 360 workers, 29 managers, and 14 medical personnel

from 12 randomly selected factories. And 3 FGDs. Evaluation:

TB data from the service records Qualitative: 270 workers, 14 managers and 11

medical personnel from randomly selected 9 factories. Plus 2 FGDs.



Partners and their roles: • Lead research organisation in Bangladesh - Society for

Empowerment, Education and Development (SEED):

– Design and deliver the project

– National (and international) dissemination

• Lead research organisation in the UK - Nuffield Centre, Leeds Institute of Health Sciences (LIHS):

– TA: development of guidelines and tools

– International dissemination and policy advocacy

• NTP:

– Political commitment, leadership, and policy support

– Guidelines, logistics, and training

• Bangladesh Garment Manufacturers and Exporters Association (BGMEA):

– Political commitment and joint supervision

– Advocacy and mobilisation

• NGOs: (BRAC, PSKP and PSTC)

– Provide TB Diagnosis, Treatment, DOT, Follow-up.



Results: 2008- 2010



Developing Partnership Model:

A systematic process has been applied to develop partnerships with the

BGMEA and garment factories in order to establish a sustainable model for

workplace TB DOTS programme; with a view to scale up.

Review and

Analyse local

Context

Advocate and

sensitise selected

corporate sector

organisations

Identify service

components

Identify potential

partners

Develop

conceptual

partnership

framework

Identify key features

and responsibilities

Develop locally

appropriate

partnership model

Small scale

implementation:

monitor and evaluate

Scale Up



Partnership Model

Sel

f ref

erra

l

Feedback

Referral

Ref

erra

l for

dia

gnos

is,

if ne

eded

Ref

erra

l

Sen

t bac

k fo

r D

OT

&

feed

back

Ref

erra

l for

spu

tum

mic

rosc

opy

Sen

t bac

k fo

r

trea

tmen

t/DO

T &

rec

ord

-

keep

ing

Ref

erra

l for

spu

tum

mic

rosc

opy

Selected garment factories for the study (n=60)

(Categorised based on the availability of on-site medical

facilities)

Category A: Garment

factories with on-site

medical corner or clinic

having both a doctor and

a paramedic (20)

Category B: Garment

factories with on-site

medical corner having a

paramedic only (19)

Category C: Garment

factories without any

medical corner or any

doctor or paramedic

(21)

Designated TB DOTS services provided by NTP/NGOs and

BGMEA Clinics

Private Medical

Practitioners (PMPs)

Garment workers

with TB symptoms



Guidelines and Tools

• Development of guidelines, communication materials and Tools: – Guidelines, referral tools – Policy Briefs, Posters, Leaflets,

factsheet – Audio materials – Featured Documentary Film

• Development of Social/Community Awareness: – Workshops on TB – Forum for “Cured Patients” – Participation in national and

local campaigns.



Number of TB suspects referred for sputum test from garment factories, and SS+ TB cases (2008-2010)



3025

35

90

11

23

0

34

4

14

3

21

45

62

38

145

0

20

40

60

80

100

120

140

160

Mirpur Ramura Dokkhinkhan Total

No

of

TB

pati

en

ts

Area

Doctor and Paramedic Paramedic Only No Medical Facility Total

Numbers of TB patients who received treatment at workplaces by type of on-site medical facility available and by area (2008-2010)



Qualitative Results: Pre-intervention scenario

• Baseline survey suggests that factory managers and garment workers were not aware of the DOTS centres operating near the garment factories,

• Factory managers were reluctant to allow TB patient to visit the DOTS centres within working hours.

• The medical personnel working in the garment factory also had inadequate knowledge on TB case management.

• All these compelled the TB patients to discontinue their job in the factory, leave the city and often discontinue TB treatment.

Poster for “TB in Workplace” delivered to the owner of a partner garment factory



‘When I joined the factory one year ago, I found out that one worker was diagnosed as a TB patient, and was still working in the factory. I was scared, as I knew TB could be transmitted to me by breathing the same air. I was really happy when the manager asked her to leave the job, and she left the factory’.

‘I have around 2000 workers in my factory. I cannot take the risk of infecting them just for 2 or 3 TB patients. My workers will also not accept this and I will face difficulty in recruiting workers’.



Qualitative Results: Post intervention scenario

• Workers, floor in-charges and managers are now aware of TB.

• There has been change in behaviour of managers. They allow leave of 7 -30 days of TB patients with the assurance to return to job.

• A service linkage has been developed. The medical personnel working in the garment factory refer the TB patients to DOTS centres, and maintains patient record. They also allow TB patients to visit the DOTS centres within working hours.



‘After the initial leave of 15 days, my manager allowed me to join the factory again. I am now getting time off to take TB drugs from the paramedic within the factory. All these were possible due to this project.’

‘I learnt from the PPP project that the government [NTP] and NGOs do good quality lab test and provide TB drugs free of cost. That’s why I went to NGO centre for my cough test. I am now taking medicine from my factory for last 3 months. This has saved me at least 4,000 taka ($50). I am better now and working in the factory’.



Influencing Policy and Practice (1)

• NTP has endorsed policy to engage garment sector in TB control;

• Growing commitment of all key stakeholders to sustain the success – MoU signed between NTP and BGMEA; NTP and SEED

• Focal point appointed in the NTP and BGMEA

• Guidelines and tools are ready to use for scale up;

• Experiences can provide motivation to other garment factories to be involved in TB control.



Workplace visited by British MPs

Influencing Policy and Practice (2)

http://www.theunion.org/index.php



Conclusion

• Demonstrates that it is possible to engage garment sector in TB control activities in order to:

• Increase access and quality of TB care for garment workers

• There is a growing commitment of the NTP, BGMEA and garment manufacturers to implement workplace TB control model

• Tools and mechanisms are ready to use

• It appears feasible to scale-up this model.

presented by: dr. a n zafar ullaha n zafar ullah nuffield centre for international health and...

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