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560\slmult0 \fs32\cf4\f0\charscalex100\b {Acknowledgements}\b0
\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-386\slmult0
\fs22\cf2\f0\charscalex100 {The Malkangiri intervention project is the product of
the combined efforts of a}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {large number of people who worked together at different
stages of the process.}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {It is impossible to mention all, and to those who have
been unknowingly or}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{for lack of space been left out, I express my gratitude \uc1\u8211X including
those, who}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {years ago
came up with the idea to develop a pictorial treatment card
for}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {neo/non-literate
DOT Providers in tribal areas of Orissa.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {The
intervention started with the teams involved in the baseline studies
in}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {2004, whose
principal investigators are all authors in this volume; DTOs
from}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {all tribal
districts of Orissa took part in a workshop to discuss and
develop}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the
intervention in December 2004. The core group who initially met
to}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {develop the
intervention consisted of Dr B. Mohanty, CDMO
(Malkangiri), }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {Dr.
R.P.Mohahatra DTO (Malkangiri), S.Mohanty (LEPRA, Bhubaneswar) and
Gopal}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {Rao, STS
(KORALEP), Tushar Ray, Santa Raye and G. Mallick, DANTB. The
two}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {NGOs, LEPRA
India and Asha Kiran contributed to and supported the
intervention}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {in
important ways throughout the process. Collector and CDMO,
Malkangiri,}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {graced
the occasion of launching the intervention on 31 March 2005.
G.Mallick,}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {Sabitri
Rout and Aruna Bhattacharya, DANTB, who traveled on many
occasions}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {to support
the initial process and the substantial training that was
undertaken;}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {Gopal
Rao, STS (KORALEP), again, for his important contribution in
the}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {training of
tribal area supervisors and sputum collection centre managers;
the}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {pharmacists and
volunteers, who gradually make diagnostic services
available}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {through
the sputum collection centres; a special thanks also to Santa
Raye}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {and Dr Mania,
SCB Medical College, Cuttack, who collaborated to develop
and}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {conduct
\uc1\u8220Xculture and communication sensitization workshops\uc1\u8221X for health
staff}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {in Malkangiri
district, and Arun K. Nayak, DANTB, who subsequently
assisted}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {in TOT for
STSs from other tribal districts; to Dr. Naik, DANTB, who
provided}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {important
input for the development of training materials for this
training;}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {the STS,
medical of\uc1\u64257Xcers and laboratory technicians of the Microscopy
Centres}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {of
Malkangiri, who increasingly appreciate the support to RNTCP
provided}\par\pard\li3786\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3786\ri0\sl-
346\slmult0 \fs16\cf4\f0\charscalex100 {iii}\par\pard\li3146\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100
{Acknowledgements}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\m
argrsxn133\margtsxn666\margbsxn106\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-426\slmult0 \fs22\cf2\f0\charscalex100 {through the
intervention. Hundreds of community DOT providers were
trained}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {in the
dif\uc1\u64257Xcult-to-access tribal parts of the intervention area by Suresh
Dungri,}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {S.K.Ojha,
Anand Charki, N. Pravu (Tribal Area Supervisors), A. Kumar
Tripathy,}\par\pard\li413\ri0\sl-293\slmult0 \fs18\cf2\f0\charscalex100 {STS, Dr.
Khora MO (PHC), Gopal Rao, N. Murti, and Appal Naidu, KORALEP,
and}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {Iren Di Silva,
Sabitri Rout, G. Mallick and A. Bhattacharya, DANTB. A very}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {warm expression of thanks, admiration and
respect goes to the community}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {DOT Providers and especially to the Tribal Area
Supervisors, Suresh Dungri,}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {S.K.Ojha, Anand Charki, and N. Pravu, who worked
tirelessly in the selection}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {and training of and supervisory support to the
community DOT Providers in}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {the dif\uc1\u64257Xcult-to-access areas of Malkangiri,
where DOTS could not reach before}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {they were involved.}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{An expression of gratitude goes also Director, Health Services, and State
TB}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Cell, Government
of Orissa, who supported the development of this
intervention}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{throughout. In important ways, in the context of the Government of India
Tribal}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {Action Plan
for RNTCP, they will also be the key for its
sustainability.}\par\pard\li6106\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li6106\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6106\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li6106\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li6106\ri0\sl-346\slmult0 \fs20\cf2\f0\charscalex100 {Jens
Seeberg}\par\pard\li6200\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {HSR
Advisor}\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
360\slmult0 \fs16\cf4\f0\charscalex100 {iv}\par\pard\li2386\ri0\sl-186\slmult0
\fs16\cf2\f0\charscalex100 {Accessing TB Services in a Tribal
District}\par\pard\sect\sectd\sbkpage
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386\slmult0 \fs32\cf4\f0\charscalex100\b {Contents}\b0 \par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-426\slmult0 \fs22\cf2\f0\charscalex100
{Acknowledgements }\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{Abbreviations}\par\pard\li413\ri0\sl-386\slmult0 \fs22\cf2\f0\charscalex100
{Introduction}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
280\slmult0 \fs22\cf4\f0\charscalex100\b {Part 1: The Model}\b0
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\fs18\cf0\par\pard\li40\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li40\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li40\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li40\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li40\ri0\sl-
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{iii}\par\pard\li13\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{vii}\par\pard\li120\ri0\sl-386\slmult0 \fs22\cf2\f0\charscalex100
{1}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0
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{11}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\par
d\li413\ri0\sl-386\slmult0 \fs22\cf2\f0\charscalex100 {1. The Malkangiri model for
community DOTS programme in tribal areas
13}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\cols
2\colno1\colw6986\colsr-0\colno2\colw1213\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs22\cf4\f0\charscalex100\b {Part 2:
Baseline Studies}\b0 \par\column\pard\li0\ri0\sl-213\slmult0
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d\li413\ri0\sl-386\slmult0 \*\tx7000\fs22\cf2\f0\charscalex100 {2. Access to health
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{37}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf2\f0\charscalex100 {3. Overcoming social distance: Interactions
between tribal TB
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133\cols2\colno1\colw6880\colsr-0\colno2\colw1320\pard\li773\ri0\sl-293\slmult0
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{4. Functioning of DOT providers in Malkangiri district}\par\pard\li413\ri0\sl-
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{5. Health status of tribal population in an unreached area
of }\par\pard\li773\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {Malkangiri
district}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf4\f0\charscalex100\b {Part 3: The Malkangiri
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Implementing a community DOTS intervention in }\par\pard\li773\ri0\sl-
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{Assistant District Medical Of\uc1\u64257Xcer}\par\pard\li13\ri0\sl-280\slmult0
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Control Programme}\par\pard\li0\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100
{Danish International Development Assistance}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Drug Distribution Centre}\par\pard\li0\ri0\sl-
280\slmult0 \fs20\cf2\f0\charscalex100 {Directly observed treatment, short-
course}\par\pard\li13\ri0\sl-293\slmult0 \fs18\cf2\f0\charscalex100 {DOT
provider}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {District
Tuberculosis Of\uc1\u64257Xcer}\par\pard\li0\ri0\sl-280\slmult0
\fs20\cf2\f0\charscalex100 {Government of Orissa}\par\pard\li13\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Grade}\par\pard\li0\ri0\sl-280\slmult0
\fs20\cf2\f0\charscalex100 {Haemoglobin}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Health Development Initiative}\par\pard\li13\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Health systems
research}\par\pard\li13\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100
{Height}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Integrated
Child Development Services}\par\pard\li13\ri0\sl-280\slmult0
\fs20\cf2\f0\charscalex100 {Information, education and
communication}\par\pard\li0\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{Jadheswar Grama Unayana Samiti}\par\pard\li0\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Lady Health Visitor}\par\pard\li2106\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li2106\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2106\ri0\sl-
200\slmult0 \fs16\cf4\f0\charscalex100 {vii}\par\pard\li1693\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100
{Abbreviations}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\marg
rsxn133\margtsxn666\margbsxn106\cols2\colno1\colw1666\colsr-
0\colno2\colw6533\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
400\slmult0 \fs18\cf2\f0\charscalex100 {LRTI}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {LT}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {MC}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {MHU}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {MO}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {MO-TU}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {MP}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {MPHW}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {NAC}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {NCDS}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {NGO}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {NLDP}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {NTP}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {OBC}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {ORS}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {PHC}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {PHI}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {PRI}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {RMP}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {RNTCP}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {RSC}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {SC}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {SCC}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {SHC}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {SHG}\par\pard\li413\ri0\sl-280\slmult0
\fs20\cf2\f0\charscalex100 {ST}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {STLS}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {STS}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {TAS}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {TB}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {TBA}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {URTI}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Vit.A def.}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {WHO}\par\pard\li413\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {WKS}\par\pard\li413\ri0\sl-280\slmult0
\fs18\cf2\f0\charscalex100 {WT}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Z-N Stain}\par\column\pard\li13\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li13\ri0\sl-400\slmult0 \fs20\cf2\f0\charscalex100 {Lower
respiratory tract infection}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Laboratory Technician}\par\pard\li0\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Microscopy Centre}\par\pard\li13\ri0\sl-
280\slmult0 \fs20\cf2\f0\charscalex100 {Mobile Health Unit}\par\pard\li13\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Medical
Of\uc1\u64257Xcer}\par\pard\li13\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100
{Medical Of\uc1\u64257Xcer-Tuberculosis Unit}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Malaria parasite}\par\pard\li0\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Multipurpose Health Worker}\par\pard\li0\ri0\sl-
280\slmult0 \fs20\cf2\f0\charscalex100 {Noti\uc1\u64257Xed Area
Council}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Nabakrushna
Choudhury Centre for Development Studies}\par\pard\li13\ri0\sl-280\slmult0
\fs20\cf2\f0\charscalex100 {Non-governmental organization}\par\pard\li13\ri0\sl-
293\slmult0 \fs18\cf2\f0\charscalex100 {Non/Neo-Literate DOT
Provider}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {National Tuberculosis Programme}\par\pard\li13\ri0\sl-
280\slmult0 \fs18\cf2\f0\charscalex100 {Other Backward
Classes}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Oral
rehydration solution}\par\pard\li0\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100
{Primary Health Centre}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{Peripheral health institution}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Panchayati raj institution}\par\pard\li13\ri0\sl-
280\slmult0 \fs20\cf2\f0\charscalex100 {Registered medical
practitioner}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Revised
National Tuberculosis Control Programme}\par\pard\li13\ri0\sl-280\slmult0
\fs20\cf2\f0\charscalex100 {Resettlement colony}\par\pard\li13\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Scheduled Caste}\par\pard\li13\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Sputum Collection
Centre}\par\pard\li13\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100 {Subsidiary
Health Centre}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Self-
help group}\par\pard\li13\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100 {Scheduled
Tribe}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Senior
Tuberculosis Laboratory Supervisor}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Senior Treatment Supervisor}\par\pard\li13\ri0\sl-
280\slmult0 \fs20\cf2\f0\charscalex100 {Tribal Area
Supervisor}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{Tuberculosis}\par\pard\li13\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100
{Traditional (Trained) Birth Attendant}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Upper respiratory tract
infection}\par\pard\li13\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Vitamin A
de\uc1\u64257Xciency}\par\pard\li13\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100
{World Health Organization}\par\pard\li13\ri0\sl-293\slmult0
\fs18\cf2\f0\charscalex100 {Weeks}\par\pard\li13\ri0\sl-280\slmult0
\fs20\cf2\f0\charscalex100 {Weight}\par\pard\li13\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Zeihi-Neilson stain}\par\pard\li2053\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li2053\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2053\ri0\sl-
280\slmult0 \fs16\cf4\f0\charscalex100 {viii}\par\pard\li720\ri0\sl-186\slmult0
\fs16\cf2\f0\charscalex100 {Accessing TB Services in a Tribal
District}\par\pard\sect\sectd\sbkpage
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373\slmult0 \fs26\cf4\f0\charscalex100\b {Malkangiri}\b0
\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
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{Introduction}\b0 \par\column\pard\li0\ri0\sl-280\slmult0
\fs24\cf2\f0\charscalex100 {Renu Addlakha and Jens
Seeberg}\fs14\cf2\f0\charscalex100
{1}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\pard
\li413\ri0\sl-280\slmult0 \fs22\cf2\f0\charscalex100 {India has the highest number
of TB cases in the world accounting for more than }\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {one third of the global disease burden. TB
kills more people in India than any }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {other infectious disease. Approximately 1,000 people
die from TB every day }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {(2005). Every year, 30,000 children are forced to leave
school because their }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{parents have tuberculosis, and 100,000 women lose their status as mothers
and }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {wives on
account of the social stigma associated with the disease. In fact,
TB }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {kills more women
in India than all causes of maternal mortality combined. TB
is }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {clearly a factor
in social development and its control becomes an integral part
of }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {poverty
reduction. Consequently, it has got high priority within the health
sector }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {in India.
Directly observed treatment, short-course (DOTS) is the main pillar
of }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the Revised
National Tuberculosis Control Programme (RNTCP). The
operational }\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{feasibility of DOTS in the Indian context has been repeatedly demonstrated,
with }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {eight out of
10 patients treated in the programme being cured, as
compared }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {with
approximately three out of 10 treated in the earlier National TB
Control }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {Programme.
RNTCP has been implemented in a phased manner, extending
the }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {programme to
the entire country by 2005. International agencies such as
the }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {World Health
Organization (WHO), the World Bank and Danish
International }\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{Development Assistance (Danida) have provided assistance to
RNTCP. }\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
413\slmult0 \fs26\cf4\f0\charscalex100\b {Orissa}\b0 \par\pard\li413\ri0\sl-
280\slmult0 \fs22\cf2\f0\charscalex100 {In a population of 37 million in the state
of Orissa (Census of India, 2001),}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {there are around 80,000 new cases of TB, with more than
19,000 deaths every}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{year. RNTCP is being implemented in Orissa with support from Danida
since}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {1997 in the
form of the Danish Assistance to the Revised National
Tuberculosis}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {Control
Programme (DANTB) project. By the end of 2004, the entire state
was}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {covered by the
programme. Orissa has adopted a decentralized
organizational}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{structure for the implementation of RNTCP involving the state, district
and}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
253\slmult0 \fs8\cf2\f0\charscalex100 {1}\fs12\cf2\f0\charscalex100 { Renu Addlakha
is a freelance researcher and DANTB consultant; Jens Seeberg is HSR Advisor,
DANTB}\par\pard\li3773\ri0\sl-400\slmult0 \fs16\cf4\f0\charscalex100
{1}\par\pard\li3360\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{Introduction}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margr
sxn133\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\margt
sxn666\margbsxn106\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
413\slmult0 \fs22\cf2\f0\charscalex100 {primary health care levels, with the DOT
provider playing a crucial role in}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {treatment. A uniform approach for programme
implementation and coverage}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {seems to be unrealistic because of the
heterogeneity of the population,}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {language and socio-cultural behaviour as well as
geographical inaccessibility}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {of in any areas. The service-bene\uc1\u64257Xciary gap
is particularly marked in the case}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {of tribal populations in hilly and forested areas
requiring local adaptations to}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {ensure quality coverage.}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{There are over 62 tribes in Orissa constituting 22% of the state\uc1\u8217Xs
population.}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {Tribal
communities are marginalized from mainstream society in
important}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {ways. They
often live in a harsh geographical environment with no
control}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {over natural
resources and limited access to public utilities like
electricity,}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {water
and sanitation, transport and communication, and health and
education.}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {In
addition, negative stereotypes and discriminatory practices by non-
tribal}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {people
further marginalize tribal communities. They are often perceived
to}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {be primitive,
superstitious and insular leading to their social isolation and
a}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {diminished quality
of life. DANTB has taken a different viewpoint. With its
focus}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {on vulnerable
populations, developing community participation to increase}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {RNTCP coverage in tribal-dominated areas
has always been a thrust area of}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {DANTB\uc1\u8217Xs work, producing IEC materials in
tribal languages and disseminating}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {key messages on TB through street theatre and song and
dance as priority}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{activities.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
400\slmult0 \fs26\cf4\f0\charscalex100\b {Malkangiri district}\b0
\par\pard\li413\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100 {Malkangiri district
in southern Orissa is one of the least-developed districts
in}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {India. With 80%
households below the poverty line (BPL) and 30.5% literacy}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {rate (below 10% in some areas and even less
among women), the district ranks}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {below the national average in most human development
indices.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf2\f0\charscalex100 {Malkangiri district came into existence as
a distinct administrative unit }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {on October 2, 1992, upon the division of the undivided
Koraput district }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{into four districts, viz. Koraput, Rayagada, Navrangpur and
Malkangiri. }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{Administratively, the district is divided into three }
{ }\fs20\cf2\f0\charscalex100 {tehasils and seven }\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {community development blocks.
It has 878 inhabited villages distributed }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {over 108 }\fs20\cf2\f0\charscalex100 {gram panchayats
(village councils). Ninety-four per cent of the }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {population is rural, thinly dispersed in remote
villages. The sex ratio of the }\par\pard\li3786\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3786\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{2}\par\pard\li2386\ri0\sl-186\slmult0 \fs16\cf2\f0\charscalex100 {Accessing TB
Services in a Tribal
District}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
3\margtsxn666\margbsxn93\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {district is
996 females per 1000 males, which is above the state average
of }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {972. The
population density is only 83 persons per square kilometre.
Low }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {population
density and general geographical inaccessibility result in
large }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {numbers of
people remaining out of the ambit of state-sponsored
services }\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {like
education and health.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs22\cf2\f0\charscalex100 {The main
tribal communities of the district are the Bondas, Koyas,
Bhumias,}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {Parojas,
Kondhs, Gadabas, Didayis, Natias, Dharuas and Halvas. Most of
these}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {communities
continue to maintain their unique culture, re\uc1\u64258Xected in
distinctive}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{languages, dress, food habits, customs and traditions. Their
subsistence}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{livelihood revolves around forests, livestock and shifting cultivation.
However,}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {many
individuals from these groups are in transition as they integrate
into}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {mainstream
society using Oriya and Telugu languages and adopting
non-}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {traditional
dress and diets. }\fs22\cf2\f0\charscalex100 {Panchayati raj (village-level
governance) institutions}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {are replacing hereditary leadership patterns based on
clan membership even}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{in the interior remote areas.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs22\cf2\f0\charscalex100 {After the
birth of Bangladesh in 1971, the Government of India
resettled}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {Bengali
refugees from former East Pakistan in Malkangiri district. They
are}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {mainly engaged
in agriculture and petty trading. They constitute a
sizeable}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {proportion
of the population being settled under the so-called DNK
project.}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {Their
settlement has better access to roads and they are marginally
better}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {off than
the local tribal communities and people belonging to
Scheduled}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{Castes.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf2\f0\charscalex100 {The construction of joint hydroelectric
power projects between the governments}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {of Andhra Pradesh and Orissa, such as Machhkund in 1949
and Balimela in}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{1962, resulted in the displacement of many tribal communities. For
instance,}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {the
construction of the Balimela reservoir resulted in the displacement of
2,000}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {tribal
households. For the affected people, the impact of these
development}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {projects
goes beyond the loss of land and livelihood as they disrupt an
entire}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {way of life.
Destruction of vegetation means age-old life-sustaining
activities}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {like
hunting, food gathering and collecting fuel and medicinal plants
are}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {adversely
affected. Physical dispersal of villages not only led to a
weakening}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {of a way
of life but also to the dilution of social and kinship bonds that
had}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {united the
people for ages.}\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{3}\par\pard\li3360\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{Introduction}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margr
sxn133\margtsxn666\margbsxn106\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {The
Balimela dam submerged a large area of Kudumulgumma block
forcing}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {local
inhabitants to move to the hills beyond the dam. This block is
traversed}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {by the
reservoir of the Balimela dam project, Korkunda and Khairput blocks
of}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {Malkangiri
district and Andhra Pradesh. It is geographically the third
largest}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {block of the
district covering an area of 569.56 sq km with 252
inhabited}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {villages
and 9,162 households. Of\uc1\u64257Xcially, the area of Kudumulgumma
block}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {separated by
Balimela dam is called the \uc1\u8216XCut-off area\uc1\u8217X. The Balimela
water}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {reservoir
physically separates the southern side of the block that covers
six}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {gram panchayats.
Three gram panchayats, namely, Jodambo, Panasput and}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Andarapalli, can only be reached by
crossing the reservoir by government}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {launch service from Chitrakonda. It takes about four to
eight hours to reach the}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {Cut-off area. Geographical inaccessibility coupled with
poor transport system}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{has isolated this part of the block from most of the government-
sponsored}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{development activities. Many of the villages do not have roads,
electricity,}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {tube
wells,}{ }\fs20\cf2\f0\charscalex100 {anganwadi centres and other infrastructural
facilities to support}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{a basic standard of living. Movement is either by motorbike or on foot.
The}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Cut-off area has
no functional schools and only a skeletal health system.
The}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {literacy rate
stands at a dismal 10%. Two mobile units comprising a
pharmacist,}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {an
Ayurvedic doctor and a female health worker try to cover the entire
area.}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {The absence of
basic infrastructure in the Cut-off area clearly indicates
that}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {resources have
not been invested commensurate with the needs of the people}\par\pard\li413\ri0\sl-
306\slmult0 \fs22\cf2\f0\charscalex100 {in this inhospitable
area.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf2\f0\charscalex100 {In addition to being an area endemic with
malaria, other diseases prevalent }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {in the district include gastrointestinal infections
such as diarrhoea, dysentery, }\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {pneumonia, yaws and respiratory diseases including TB.
In the local ethno-}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{medical systems, evil spirits and deities are the main aetiological
agents }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {of
different af\uc1\u64258Xictions. Traditional doctors, variously known as }
{ }\fs20\cf2\f0\charscalex100 {disari, }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {bejius, gunia and siras propitiate the spirits
through elaborate rituals, }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {animal sacri\uc1\u64257Xces and other ceremonies.
Herbal preparations are also used as }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {medicines. Faith in the ef\uc1\u64257Xcacy
of Western medicine is low. However, more }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {people are approaching the modern health system even if
in the form of }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{local drug vendors, while they continue to use the traditional systems
as }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {well.
Utilization of state health facilities is determined by a host of
factors }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {such as
seriousness of the problem, access to a health centre and
behaviour }\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {of the
health functionary.}\par\pard\li3786\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3786\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{4}\par\pard\li2386\ri0\sl-186\slmult0 \fs16\cf2\f0\charscalex100 {Accessing TB
Services in a Tribal
District}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
3\margtsxn666\margbsxn93\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {Eleven
microscopy centres notwithstanding, large areas of Malkangiri
district}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {remained
poorly covered by RNTCP. The cure rate was only 67% as
against}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {the national
norm of 85%. For a population of 600,000 in the district,
there}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {are only 11
microscopy centres. Since 1962, a government TB hospital in
the}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Mathili block of
Malkangiri has been attracting many people from
neighbouring}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {states
such as Bihar, Andhra Pradesh and Madhya Pradesh. Overall, there is
an}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {urgent need to
enhance awareness about RNTCP among the people, establish}\par\pard\li413\ri0\sl-
306\slmult0 \fs20\cf2\f0\charscalex100 {more accessible facilities for sputum
testing and increase the number of local}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {DOT providers on a priority
basis.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
413\slmult0 \fs26\cf4\f0\charscalex100\b {Outline of the book}\b0
\par\pard\li413\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100 {This book covers
different aspects of the DANTB-initiated Malkangiri
\uc1\u8216Xreaching}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{the unreached\uc1\u8217X project. Part I describes the four baseline studies on
illness}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {patterns
and health-seeking behaviour of dominant tribal groups and
the}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {functioning of
the local health care system in Malkangiri district. Part
II}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {gives a detailed
description of the pilot intervention and subsequently its}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {evaluation after a six-month period. The
Malkangiri intervention drew upon}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {different dimensions of DANTB work in a consolidated
fashion, i.e. IEC in the}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {development of pictorial treatment cards,
infrastructure development in setting}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {up of sputum collection centres, capacity building in
training of community}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{DOT providers and community participation.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {The
\uc1\u64257Xrst chapter is a community study conducted in seven villages by
the}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {Nabakrushna
Choudhury Centre for Development Studies (NCDS), which
found}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {that the
tribal communities were generally marginalized in comparison
to}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the mainstream
society of towns where non-local people held most of the}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {in\uc1\u64258Xuential positions. The aim of
this study was to examine the health-seeking}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {behaviour and health delivery system in one of the most
inaccessible and under-}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {developed regions of the country, namely, Kudumulgumma
block in Malkangiri}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{district. A cross-section of informants, including health providers and
general}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {public, were
interviewed on a range of health-related issues, particularly
RNTCP}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {activities.
Primary data were collected using an approach with mixed
methods}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {including
in-depth interviews, household surveys, participant observation
and}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {secondary data.
The chapter contains a detailed discussion of RNTCP in the}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Cut-off area within the larger context of
health conditions, service utilization}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {and coverage by a wide range of health care providers.
Unpleasant experiences}\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{5}\par\pard\li3360\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{Introduction}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margr
sxn133\margtsxn666\margbsxn106\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {with
government health services and mistrust of service providers were
found}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {to be
widespread. Traditional healers and quacks, who are easily accessible
to}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {the people, were
the \uc1\u64257Xrst to be consulted in case of illness.}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{In the second chapter, Rikke Aarhus, a Danish student who conducted
her}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {study in
collaboration with NCDS and DANTB, discusses tuberculosis
treatment}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {in and
around Chitrakonda. She points out that in DOTS, for the
treatment}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {to be
successful, it is important that the relationship between the
patient}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {and the
provider should go off well. It is pointed out in the study that
social}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {distance
between the provider and the patient hinders a bene\uc1\u64257Xcial
outcome}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {of the
interaction, i.e. a successful treatment. The social distance derives
from}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {different
ethnic backgrounds of the provider and the patient and a
consequential}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{unequal relationship. In this area most patients belong to tribal
communities}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {while
the providers are Oriya. Although physical distance also plays a role
in}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{patients\uc1\u8217X access to health centres, this factor is easier to overcome
than the}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {social
distance. To reduce social and physical distances and thus improve
the}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {functioning of
TB treatment, it is recommended that local non-health
persons}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {be trained
to function as DOT providers (DPs). As many of the non-health
DPs}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {will be
illiterate, pictorial aids should also be introduced. The present
system}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {of outside
supervisors should also be replaced with a system of
supervisors}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {with
local knowledge and commitment.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {One of the
key components of the DOTS programme is the performance of
DPs.}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {Their work is
critical in ensuring direct supervision of treatment as well
as}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {monitoring of the
programme. A baseline study to understand the functioning}\par\pard\li413\ri0\sl-
306\slmult0 \fs20\cf2\f0\charscalex100 {and working conditions of health DPs in
Malkangiri district is contained in}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {the third chapter of this volume. In-depth interviews
were conducted with}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{81 active health DPs on different aspects of their work. Other
stakeholders}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{including district health of\uc1\u64257Xcials, especially senior treatment
supervisors}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {(STS),
senior TB laboratory supervisors (STLS) and medical of\uc1\u64257Xcers
(MOs),}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {patients and
general public were also interviewed on TB and on the work
of}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {DPs. It was found
that most of the DPs were women from the coastal parts}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {of Orissa. They faced many problems in
attending to patients in far-\uc1\u64258Xung}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {tribal villages. Dif\uc1\u64257Xcult terrain, scattered
habitations, inadequate means of}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {transport, an unfamiliar cultural milieu and concerns
about personal safety}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{were some of the main constraints they faced. Even though functioning as
a}\par\pard\li3786\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3786\ri0\sl-
346\slmult0 \fs16\cf4\f0\charscalex100 {6}\par\pard\li2386\ri0\sl-186\slmult0
\fs16\cf2\f0\charscalex100 {Accessing TB Services in a Tribal
District}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
3\margtsxn666\margbsxn93\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {DP does
entail additional investment of time with no corresponding
\uc1\u64257Xnancial}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{returns, many DPs said they were motivated to help cure TB patients out
of}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {a sense of
professional duty, religious conviction or moral responsibility.
An}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {urgent need was
identi\uc1\u64257Xed not only to increase the number of DPs in the
area}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {but to address
the problems they faced in their day-to-day work.
Furthermore,}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{innovative approaches leading to community participation and local
ownership}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {of RNTCP
needed to be developed.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {The fourth
and last baseline study was a health survey undertaken in the
same}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {nine
dif\uc1\u64257Xcult-to-access villages of Kudumulgumma and Korkonda blocks
in}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Malkangiri
district where community studies were undertaken. Villages
were}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {further
strati\uc1\u64257Xed as hilly or dif\uc1\u64257Xcult, the latter being located in
the Cut-off}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {area.
The Department of Community Medicine, Maharaja K.C. Gajapati
Medical}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {College,
Berhampur, conducted the study covering 1,432 individuals in
394}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {households in
these nine villages. Diagnosis of ailments was facilitated by
basic}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {laboratory
investigations in the \uc1\u64257Xeld. Cases diagnosed during the
household}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {survey
were given treatment on the spot and referral for further
investigation}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {and/or
treatment, if necessary.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Anaemia,
fever/malaria, respiratory diseases, goitre, musculo-skeletal
disorders}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {and
diseases involving the eyes, skin, teeth and ears were the most
prevalent}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {disorders
in the study population. Fourteen deaths were enumerated
during}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {the past year
prior to the survey, with fever/malaria being cited as the
most}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {common cause of
death (57.1% of cases). Enlarged spleen, associated with}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {fever/malaria, male sex and residence in
dif\uc1\u64257Xcult areas, was present in 24.9%}\par\pard\li413\ri0\sl-
306\slmult0 \fs20\cf2\f0\charscalex100 {of the study population, with children
being signi\uc1\u64257Xcantly affected. 61.9% of}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {the sample had different degrees of anaemia. It was
associated with suspected/}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {con\uc1\u64257Xrmed malaria and splenomegaly (64.3%)
and residence in dif\uc1\u64257Xcult areas}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {(68.7%). Respiratory infections (21.8%) and diarrhoeal
disorders (2.5%) were}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{found in lower age groups, whereas eye problems (11.0%) like cataract
and}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {visual
impairment were found in older people. About one-\uc1\u64257Xfth of the
study}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {population
suffered from some musculo-skeletal problems, predominantly
low}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {back pain and
different joint involvements. Goitre was present in 13.7%
of}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the population.
12.9% children below 15 years of age were undernourished.}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {On the other hand, 22.9% persons above 15
years of age had different grades}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {of underweight.}\par\pard\li3773\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3773\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{7}\par\pard\li3360\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100
{Introduction}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margr
sxn133\margtsxn666\margbsxn106\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {All
individuals were screened for chronic cough and chest symptoms.
Sputum}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {for AFB was
done in 39 chest symptomatic persons having chronic cough.}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Many had multiple TB symptoms. Upon
subsequent sputum test, only two were}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {found sputum positive.}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{On the basis of the above \uc1\u64257Xndings, it was suggested that the prevailing
health}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {problems like
malaria, anaemia and respiratory infections must be
addressed}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {through
integrated services to ensure regular and complete treatment in
TB}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {cases.
Prophylaxis for anaemia and malaria may be considered along with
anti-}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {TB treatment
to improve compliance. DPs should receive training on
locally}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {prevalent
health conditions not only to make them more effective
RNTCP}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {providers but
also to enable them to address the health needs of the
people}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {in a holistic
manner.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {In the light of the four exploratory
studies on health problems and the health}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {system in Malkangiri district, an intervention to
increase RNTCP coverage was}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {developed in 2005 by DANTB in partnership with the
district health authority}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {and LEPRA India, an NGO with extensive grass-roots
presence on health issues.}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {Given the geographical inaccessibility, huge physical
distances between sparsely}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {populated villages and the social and cultural
distances between the people and}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {health providers, a composite package emphasizing
inter- and intra-sectoral}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {collaboration and community participation was developed
to increase TB case}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{detection and treatment completion.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf4\f0\charscalex100
{\uc1\u8226X}\fs20\cf2\f0\charscalex100 { To increase TB case detection and access
to TB services among dif\uc1\u64257Xcult-}\par\pard\li773\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {to-reach populations;}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf4\f0\charscalex100
{\uc1\u8226X}\fs20\cf2\f0\charscalex100
{ To develop community DOTS, using provider-friendly pictorial
treatment}\par\pard\li773\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {cards for
case-holding and monitoring;}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf4\f0\charscalex100
{\uc1\u8226X}\fs20\cf2\f0\charscalex100 { To decrease social distance between
service providers and communities}\par\pard\li773\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {through culture and communication
workshops;}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf4\f0\charscalex100 {\uc1\u8226X}\fs20\cf2\f0\charscalex100
{ To develop a government-NGO interface for management of
sputum}\par\pard\li773\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {collection,
case detection and supervision.}\par\pard\li3786\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3786\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3786\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3786\ri0\sl-226\slmult0 \fs16\cf4\f0\charscalex100
{8}\par\pard\li2386\ri0\sl-186\slmult0 \fs16\cf2\f0\charscalex100 {Accessing TB
Services in a Tribal
District}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
3\margtsxn666\margbsxn93\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {The pillar
of the intervention was the establishment of a corps of
community}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {DOT
providers in remote tribal areas with low literacy rates and limited
access}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {to health
care. This involved developing appropriate IEC and training
materials}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {to equip
the non- or neo-literate DOT providers (NLDPs) to understand TB
as}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {a public health
problem in their area, to generate awareness about it at
local}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {level, to help
symptomatic persons access microscopy services and to
supervise}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {treatment
of identi\uc1\u64257Xed cases based on the principles of DOTS. As many
as}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {505 non-/neo-
literate volunteers were trained as DOT providers in the
course}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {of the
intervention. They were trained to use a pictorial treatment card
to}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {chart
patients\uc1\u8217X treatment. Due to the inaccessible places of habitation, it
was}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {not possible for
the two senior treatment supervisors (STS) in Malkangiri to}\par\pard\li413\ri0\sl-
306\slmult0 \fs20\cf2\f0\charscalex100 {adequately supervise the community DPs.
Consequently, tribal area supervisors}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {(TAS) were identi\uc1\u64257Xed to serve as a link
between the government health system,}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {community DPs and patients. Four such tribal area
supervisors were appointed}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {to cover the three blocks in which the intervention was
implemented.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {The distance between the microscopy centre
and the patient\uc1\u8217Xs villages made it}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {dif\uc1\u64257Xcult for them to give a sputum test for
diagnosis. To address this problem,}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {sputum collection centres (SCC) were conceptualized and
manned either by a}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{pharmacist or a local volunteer, whose main function was to dispense
containers}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {to
symptomatic persons and prepare slides of the sputum samples to be
sent}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {to the nearest
microscopy centre (MC) for examination. Ten such SCCs were}\par\pard\li413\ri0\sl-
293\slmult0 \fs22\cf2\f0\charscalex100 {started at strategic locations in the
intervention blocs.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {In
addition to the involvement of tribal communities in RNTCP
through}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the training
of community DPs and through the appointment of TASs, two}\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {culture and communication workshops were
held to sensitize health system}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {functionaries to the special needs of tribal
patients.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {The Koraput unit of LEPRA India, an NGO
with extensive presence and experience}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {in the area, and Asha Kiran, an NGO running a local
hospital, were involved}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {as partners to implement the
intervention.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {A \uc1\u64257Xnal evaluation was
commissioned by DANTB from mid-September to mid-}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {October 2005. It was conducted by Health Development
Initiative (HDI) and}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{NCDS. The objectives of the study were to carry out a rapid and
comprehensive}\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
346\slmult0 \fs16\cf4\f0\charscalex100 {9}\par\pard\li3360\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100
{Introduction}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margr
sxn133\margtsxn666\margbsxn106\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {assessment
of the functioning of the central components of the
intervention,}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{namely:}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf4\f0\charscalex100 {\uc1\u8226X}\fs20\cf2\f0\charscalex100
{ Performance of the newly-trained non-/neo-literate community
DOT}\par\pard\li773\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {providers
(NLDPs);}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf4\f0\charscalex100 {\uc1\u8226X}\fs22\cf2\f0\charscalex100
{ Performance of the newly-appointed tribal area supervisors
(TAS);}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf4\f0\charscalex100 {\uc1\u8226X}\fs20\cf2\f0\charscalex100
{ Functioning of the ten recently established sputum collection
centres}\par\pard\li773\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{(SCCs);}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf4\f0\charscalex100 {\uc1\u8226X}\fs22\cf2\f0\charscalex100
{ Use of and experience with pictorial treatment cards;}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf4\f0\charscalex100
{\uc1\u8226X}\fs20\cf2\f0\charscalex100 { Collaboration of district health
authorities with NGOs in carrying out the}\par\pard\li773\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {intervention.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs22\cf2\f0\charscalex100 {While the
intervention was only fully functional by end-June, it was
necessary }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {to
conduct the evaluation commissioned by DANTB in late September due to
the }\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {closing down of
the DANTB project by end-2005. It was necessary to obtain a
basis }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {on which the
Government of India and the Government of Orissa could
decide }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {whether to
extend the intervention period beyond 2005 to further
consolidate }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the
intervention model in order to assess its potential for sustainability
and }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {scaling up.
The evaluation \uc1\u64257Xndings suggested that the intervention
had }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {considerably
increased people\uc1\u8217Xs general awareness about TB and its treatment
in }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {many remote
villages. While a number of hidden cases had been identi\uc1\u64257Xed
and }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {put on
treatment, the main improvement seemed to have been in case-
holding }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {where
defaulting (as seen at an early point in time) showed a dramatic
decrease. }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {The
newly-trained community NLDPs were playing a major role in
awareness }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{generation and treatment supervision and the pictorial treatment card had
been }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {successful in
enabling non-/neo-literate DPs to provide treatment. The work
of }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {TASs as
link workers between the health system and local communities had
been }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {highly
appreciated both by district health functionaries and local people. Due
to }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {some delay, the
sputum collection centres were less successful but were
gradually }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {receiving
cases for sputum examination. However, in order for the impact of
the }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {intervention to
be fully assessable, the intervention period should be
extended }\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {for a
period of one more year and evaluated after a suitable period of
time.}\par\pard\li3746\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-
346\slmult0 \fs16\cf4\f0\charscalex100 {10}\par\pard\li2386\ri0\sl-186\slmult0
\fs16\cf2\f0\charscalex100 {Accessing TB Services in a Tribal
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\fs42\cf2\f0\charscalex100\b {PART 1}\b0 \par\pard\li640\ri0\sl-653\slmult0
\fs42\cf4\f0\charscalex100\b {THE MODEL}\b0
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3960\ri0\sl-280\slmult0 \fs24\cf2\f0\charscalex100 {Renu Addlakha and Jens
Seeberg*}\par\pard\li1240\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1240\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li1240\ri0\sl-213\slmult0
\fs18\cf0\par{\trowd\trleft1240\trkeep\trftsWidth1\trpaddl0\trpaddr0\trpaddfl3\trpa
ddfr3
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lrtb\clNoWrap\clftsWidth3\clwWidth386\clpadt0\clpadr0\clpadft3\clpadfr3\cellx2293 \
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{1}\cell\clvertalt\clbrdrt\brdrnone\clbrdrl\brdrnone\clbrdrb\brdrnone\clbrdrr\brdrn
one\cltxlrtb\clNoWrap\clftsWidth3\clwWidth5706\clpadt0\clpadr0\clpadft3\clpadfr3\ce
llx8106 \pard\li0\ri0\sl-560\widctlpar\intbl \fs32\cf4\f0\charscalex100\b {The
Malkangiri model for community}\b0 \par\pard\li0\ri0\sl-480\widctlpar\intbl
\fs32\cf4\f0\charscalex100\b {DOTS programme in tribal areas}\b0
\cell\row}\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-360\slmult0 \fs22\cf2\f0\charscalex100
{Tribal communities live in geographical isolation, mainly in inaccessible
hilly}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {and forested
areas. They are often regarded as primitive and backward
and}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {occupy the
lowest position in the social hierarchy of traditional Hindu
society.}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {They have
distinctive cultural beliefs and practices, which set them apart
from}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {mainstream
society. Physical inaccessibility intersects with socio-
cultural}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{marginalization to render them the poorest among the poor in the
country.}\fs14\cf2\f0\charscalex100 {1}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {Absence of basic infrastructure like all-weather
roads, water, electricity,}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {transportation, communication, health and education
frequently make it}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100
{very dif\uc1\u64257Xcult not only for tribal people to access basic services but
also for}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {government
programmes like RNTCP to reach them.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs22\cf2\f0\charscalex100 {The
overwhelming majority of health service providers are non-tribal,
and}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {they are often
reluctant to take up positions in physically remote and
under-}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {developed
tribal areas. Such postings are avoided at all costs and
frequent}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {transfers
are the norm, resulting in severe manpower shortages at
provider}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {level. As
the study of health DPs in this volume shows, health workers
generally}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {prefer to
stay at block headquarters visiting their area of operation a
couple}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {of times
during the month at the most. Absence of accommodation at
sub-}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {centres, lack
of transport at their disposal and other factors deter
them,}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {particularly
women, from going to the interior tribal villages. But
perhaps}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {the most
important factor obstructing the functioning of the health
system}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {in tribal
areas like Malkangiri district in Orissa is the perception about
tribal}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {society and
their culture among non-tribal people. As the authors
highlight}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {in the
context of leprosy elimination in tribal areas:}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-253\slmult0 \fs8\cf2\f0\charscalex100
{*}\fs12\cf2\f0\charscalex100 { Renu Addlakha is a freelance researcher and DANTB
consultant; Jens Seeberg is HSR Advisor, DANTB}\par\pard\li413\ri0\sl-
253\slmult0 \fs8\cf2\f0\charscalex100 {1}\fs12\cf2\f0\charscalex100 { R.K.
Mutatkar: Report on health issues in Nandurdar district, Maharashtra. Human
Development Action Research Study.}\par\pard\li413\ri0\sl-173\slmult0
\fs12\cf2\f0\charscalex100 {Maharashtra Association of Anthropological Sciences,
2004: Pune.}\par\pard\li3773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3773\ri0\sl-
360\slmult0 \fs16\cf4\f0\charscalex100 {13}\par\pard\li1306\ri0\sl-200\slmult0
\fs16\cf2\f0\charscalex100 {The Malkangiri model for community DOTS programme in
tribal areas}\par\pard\sect\sectd\sbkpage
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i773\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li773\ri0\sl-413\slmult0
\fs22\cf2\f0\charscalex100 {\uc1\u8220XApart from the natural and material
constraints on account of poor}\par\pard\li773\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {accessibility, harsh terrain and inadequate manpower,
the quality of}\par\pard\li773\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{health care delivery in tribal areas may also be adversely affected
by}\par\pard\li773\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the general
perceptions and attitudes of non-tribal health workers, who}\par\pard\li773\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {sometimes function within a framework of
social stereotypes about}\par\pard\li773\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {tribal mentality and way of life. These stereotypes are
derived from}\par\pard\li773\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {the
same ethnocentric notions of primitivity and backwardness,
and}\par\pard\li773\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {may largely be
linked to the general ignorance about the distinctive}\par\pard\li773\ri0\sl-
293\slmult0 \fs22\cf2\f0\charscalex100 {cultures and languages of tribal
groups.\uc1\u8221X}\fs14\cf2\f0\charscalex100 {2}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-360\slmult0 \fs22\cf2\f0\charscalex100 {While
social distance from the providers\uc1\u8217X side may be manifested in
avoidance,}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {aversion
and prejudice, it is not unidirectional. Tribal people also look
upon}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {non-tribal
people with mistrust and suspicion. While using the
vernacular}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {language
in communication may attenuate some of the negativity from
both}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {sides, more
structured strategies targeting behaviour and attitudinal
change}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {are required
to overcome age-old stereotypes and perceptions.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {This
chapter presents an outline of a generic model of tuberculosis control
in}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {tribal areas,
which is derived directly from experiences with an
intervention}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {package
to enhance community DOTS in selected blocks of Malkangiri district
in}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {southern Orissa.
However, this model builds itself on the extensive
experiences}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {with
implementing RNTCP in tribal districts of Orissa since the inception
of}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the programme in
1997. It provides speci\uc1\u64257Xc guidelines for enhancing
coverage}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {and
effectiveness of RNTCP in tribal areas characterized by:}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-266\slmult0 \fs16\cf4\f0\charscalex100
{\uc1\u61548X}\fs22\cf2\f0\charscalex100 { Physical remoteness from centres of
economic and political activity;}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-306\slmult0 \fs16\cf4\f0\charscalex100
{\uc1\u61548X}\fs22\cf2\f0\charscalex100 { Scattered habitations in hilly and
forested terrain;}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-306\slmult0 \fs16\cf4\f0\charscalex100
{\uc1\u61548X}\fs22\cf2\f0\charscalex100 { Limited or no access to health care
services;}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
293\slmult0 \fs16\cf4\f0\charscalex100 {\uc1\u61548X}\fs22\cf2\f0\charscalex100
{ Widespread poverty, illiteracy and under-development;}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-306\slmult0 \fs16\cf4\f0\charscalex100
{\uc1\u61548X}\fs22\cf2\f0\charscalex100 { Social
marginalization;}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{\uc1\u61548X}\fs22\cf2\f0\charscalex100 { Distinct language and cultural
practices.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
226\slmult0 \fs6\cf2\f0\charscalex100 {2}\fs10\cf2\f0\charscalex100 { R. Addlakha
and J. Seeberg: Towards a Strategy for Leprosy Elimination in Tribal Areas. In
Addlakha and Seeberg (eds.):}\par\pard\li413\ri0\sl-186\slmult0
\fs10\cf2\f0\charscalex100 {Towards Leprosy Elimination in Tribal Communities.
Experiences from Madhya Pradesh, Orissa and Chhattisgarh, 1-28.
New}\par\pard\li413\ri0\sl-173\slmult0 \fs12\cf2\f0\charscalex100 {Delhi, 2004:
DANLEP}\par\pard\li3746\ri0\sl-293\slmult0 \fs16\cf4\f0\charscalex100
{14}\par\pard\li2386\ri0\sl-186\slmult0 \fs16\cf2\f0\charscalex100 {Accessing TB
Services in a Tribal
District}\par\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
3\margtsxn666\margbsxn93\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs22\cf2\f0\charscalex100 {The model
has been operationalized in collaboration with the district
health }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {system and
local NGOs. The model is intended as a source of inspiration
and }\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {should be
further developed and adapted to local situations where
applicable. }\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs22\cf2\f0\charscalex100 {The model consists of four complementary
components that are combined to}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {achieve a synergy effect:}\par\pard\li413\ri0\sl-
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\fs18\cf2\f0\charscalex100\b {DIAGNOSIS:}\b0 \fs22\cf2\f0\charscalex100
{ Increased access to diagnostic facilities is created
through}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {establishing
sputum collection centres to serve as outreach services
relative}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {to
microscopy centres.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs18\cf2\f0\charscalex100\b
{TREATMENT:}\b0 \fs22\cf2\f0\charscalex100 { Community DOTS is established through
a web of community DPs}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {who may be literate, neo-literate or non-literate and
who are trained to provide}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {DOT and maintain a pictorial treatment card. These DPs
must belong to local}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100
{tribal communities of the area, thereby mediating social distance
between}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {health
services and patients.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs16\cf2\f0\charscalex100\b
{SUPERVISION:}\b0 \fs20\cf2\f0\charscalex100 { Specially trained tribal area
supervisors (TAS), originating }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {from local communities, are employed and trained to
provide supportive }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{supervision to community DPs. They may work through a local NGO
and }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {coordinate
\uc1\u64257Xeld activities with relevant RNTCP of\uc1\u64257Xcers in the
general }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {health
system. They constitute the link between community DPs and
their }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {patients in
remote villages and the general health system. They also
ensure }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {accurate and
timely reporting on the basis of treatment cards and
assist }\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {in
transporting slides from sputum collection centres (SCCs) as well
as }\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {medicine boxes
to DPs.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs18\cf2\f0\charscalex100\b {COMMUNICATION:}\b0
\fs22\cf2\f0\charscalex100 { The introduction of tribal community DPs and TASs
itself}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {serves to
bridge a number of communication gaps between the health
system}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {and tribal TB
patients since language barriers are effectively mediated.
In}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {addition to that,
the communication skills and cultural sensitivity of health}\par\pard\li413\ri0\sl-
306\slmult0 \fs22\cf2\f0\charscalex100 {providers are strengthened through tailor-
made workshops.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
400\slmult0 \fs26\cf4\f0\charscalex100\b {Overall objectives}\b0
\par\pard\li413\ri0\sl-280\slmult0 \fs16\cf4\f0\charscalex100
{\uc1\u61548X}\fs22\cf2\f0\charscalex100 { To increase access to RNTCP diagnostic
and curative services in dif\uc1\u64257Xcult-}\par\pard\li773\ri0\sl-306\slmult0
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{15}\par\pard\li1306\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {The Malkangiri
model for community DOTS programme in tribal areas}\par\pard\sect\sectd\sbkpage
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\fs16\cf4\f0\charscalex100 {\uc1\u61548X}\fs22\cf2\f0\charscalex100 { To ensure
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{\uc1\u61548X}\fs22\cf2\f0\charscalex100 { To increase public awareness in remote
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system.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
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{ To reduce social distance between service providers and tribal
communities}\par\pard\li773\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {in the
intervention area.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-413\slmult0 \fs26\cf4\f0\charscalex100\b
{Rationale}\b0 \par\pard\li413\ri0\sl-280\slmult0 \fs20\cf2\f0\charscalex100 {As
has been pointed out in the baseline studies published elsewhere in
this}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {volume, prior
to the intervention, both physical distance (accessibility)
and}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {social distance
(mutual mistrust) formed important barriers to service
delivery.}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Figure 1
illustrates that health services tended to be characterized by
both}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {excessive
physical distance and mutual mistrust between providers and
patients}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {(cell 4 in
Figure 1).}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
400\slmult0 \fs24\cf5\f0\charscalex100\b {Figure 1:}\b0
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access to services. The four components of the interventions
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\fs18\cf0\par\pard\li413\ri0\sl-280\slmult0 \fs22\cf2\f0\charscalex100 {It can be
seen that different components of the intervention address a
range}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {of problems
that have obstructed RNTCP activities in an area like
Malkangiri}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {district.
It is, therefore, important to address organizational and
administrative}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{bottlenecks identi\uc1\u64257Xed in the course of the implementation of the
intervention,}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {so
that it can become a model for enhancing RNTCP coverage in remote
tribal}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {areas not
only in Orissa but also in other parts of the country. It has ful\uc1\u64257Xlled
the}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {main objective
of expanding the ambit of RNTCP services in remote
inaccessible}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {tribal
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\fs26\cf4\f0\charscalex100\b {Steps towards implementing the \uc1\u8220XMalkangiri
model\uc1\u8221X}\b0 \par\pard\li413\ri0\sl-280\slmult0 \fs22\cf2\f0\charscalex100
{The following tables present the formal design of the community DOTS
model}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {that has been
implemented in Malkangiri district as part of a health
systems}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {research
project initiated by DANTB. Due to a multiplicity of
contextual}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {factors,
the steps can only be indicative and not absolute. Local
conditions}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {and
circumstances will determine the sequencing of different activities,
their}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {timing and
operationalization. However, care should be taken to avoid a
lengthy}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {time lag
between planning and implementation of a project. Furthermore,
the}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {ultimate aim of
this intervention is not to replace RNTCP but to enhance
its}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {functioning in
dif\uc1\u64257Xcult-to-access areas through involvement of NGO
partners}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {and local
communities. By dif\uc1\u64257Xcult-to-access areas, the reference is to
far-}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {\uc1\u64258Xung
villages where health functionaries, due to a range of constraints,
are}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {not able to
deliver RNTCP services on a regular basis.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-400\slmult0 \fs24\cf5\f0\charscalex100\b {Step
1: }\b0 \fs24\cf4\f0\charscalex100\b {Selection of intervention area}\b0
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{indicators}\par\column\pard\li0\ri0\sl-413\slmult0 \fs20\cf2\f0\charscalex100
{Selection of tribal block(s) in which health centres are not}\par\pard\li0\ri0\sl-
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population due to}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
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240\slmult0 \fs20\cf2\f0\charscalex100 {area with few TB cases or high default
rates.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {State TB Cell
and/or district health authorities in}\par\pard\li0\ri0\sl-240\slmult0
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researchers.}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100
{Establishing a consensus on the need for special}\par\pard\li0\ri0\sl-
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health staff}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {and NGOs
in consultation with concerned panchayati raj}\par\pard\li0\ri0\sl-240\slmult0
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1}}}}\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\margtsxn666\margbsxn93\pard\li
413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-413\slmult0
\fs22\cf2\f0\charscalex100 {Who initiates the project? In the present era of
public-private-NGO collaboration,}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {technically, any of these can do so. Once a consensus
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\fs20\cf2\f0\charscalex100 {stakeholders, detailed baseline data needs to be
obtained to get a better}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {understanding of the area. In practice, Steps 1 and 2
may be merged, as the}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{availability of detailed background information is necessary to select
the}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {intervention
area. A consensus among different stakeholders will be
reached}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {through a
series of meetings.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-400\slmult0 \fs24\cf5\f0\charscalex100\b {Step
2: }\b0 \fs24\cf4\f0\charscalex100\b { Secondary baseline data on population and
health}\b0
\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\cols2\c
olno1\colw2346\colsr-0\colno2\colw5853\pard\li520\ri0\sl-440\slmult0
\fs20\cf2\f0\charscalex100 {Activity}\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
280\slmult0 \fs20\cf2\f0\charscalex100 {Responsible}\par\pard\li520\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {person/institution}\par\pard\li520\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {Process}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-413\slmult0 \fs20\cf2\f0\charscalex100
{Outcome}\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
413\slmult0 \fs20\cf2\f0\charscalex100 {Resources}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
253\slmult0 \fs20\cf2\f0\charscalex100 {Risks}\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
280\slmult0 \fs20\cf2\f0\charscalex100 {Assessment}\par\pard\li520\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {indicators}\par\column\pard\li0\ri0\sl-
440\slmult0 \fs20\cf2\f0\charscalex100 {Situational analysis of selected area,
including a pro\uc1\u64257Xle}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {of tribal populations, languages and cultural
practices,}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {health-
seeking behaviour, treatment options and available}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {infrastructure with special emphasis on TB situation in
the}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{area(s).}\par\pard\li0\ri0\sl-386\slmult0 \fs18\cf2\f0\charscalex100 {RNTCP and
government health service (GHS) staff, NGOs}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {and researchers.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Quantitative and qualitative data on socio-
demographic}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {and health
pro\uc1\u64257Xle, with special emphasis on TB.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Area-speci\uc1\u64257Xc database on population and
health situation}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {of
the selected area(s).}\par\pard\li0\ri0\sl-386\slmult0 \fs18\cf2\f0\charscalex100
{Block-level RNTCP and GHS reports.}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Directory of health facilities in the area from
health}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{department.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Mapping
of health infrastructure including public health}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {centres, private clinics and traditional
healers.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{Unavailability of reliable up-to-date data.}\par\pard\li0\ri0\sl-320\slmult0
\fs20\cf2\f0\charscalex100 {Unavailability of competent
researchers.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Reliable
information available on socio-economic pro\uc1\u64257Xle}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {of the people, including major illnesses
(including}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {information
on TB prevalence, local understanding and}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {treatment, access to biomedical diagnosis and
treatment),}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {number of
health facilities classi\uc1\u64257Xed by sector (public,}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {private, NGO) and system (biomedical,
indian systems of}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{medicine (ISM), other).}\par\pard\li1426\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li1426\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1426\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li1426\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li1426\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1426\ri0\sl-
240\slmult0 \fs16\cf4\f0\charscalex100
{19}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\par
d\li1306\ri0\sl-200\slmult0 \fs16\cf2\f0\charscalex100 {The Malkangiri model for
community DOTS programme in tribal
areas}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\p
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\fs20\cf2\f0\charscalex100 {and health-seeking behaviour may not be captured
through this cursory}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {exercise. Therefore, more \uc1\u64257Xeld-based
research using participatory methods}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {is preferable. Such research would not only provide
detailed information on}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {notions of health and illness, health-seeking behaviour
and patterns of resort}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {in the community but research-based discussions with
local people would also}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {bring to the foreground TB as an issue of importance in
the area. Participatory}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {rural appraisal (PRA) techniques involving researchers
and NGOs would help in}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {generating this detailed primarily qualitative health
pro\uc1\u64257Xle of the area.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-400\slmult0 \fs24\cf5\f0\charscalex100\b {Step
3:}\b0 \fs24\cf4\f0\charscalex100\b { Participatory local study on TB and
health}\b0
\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\cols2\c
olno1\colw2386\colsr-0\colno2\colw5813\pard\li520\ri0\sl-400\slmult0
\fs20\cf2\f0\charscalex100 {Activity}\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {Responsible person/}\par\pard\li520\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {institution}\par\pard\li520\ri0\sl-
333\slmult0 \fs20\cf2\f0\charscalex100 {Process}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
400\slmult0 \fs20\cf2\f0\charscalex100 {Outcome}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
266\slmult0 \fs20\cf2\f0\charscalex100 {Resources}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{Risks}\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{Assessment}\par\pard\li520\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{indicators}\par\column\pard\li53\ri0\sl-400\slmult0 \fs20\cf2\f0\charscalex100 {To
understand local disease models of TB, its cause, }\par\pard\li53\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {diagnosis course, treatment and prognosis
in the selected }\par\pard\li53\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{area(s) through participatory research methodology. }\par\pard\li53\ri0\sl-
333\slmult0 \fs18\cf2\f0\charscalex100 {RNTCP and GHS staff, NGOs, other
stakeholders community-}\par\pard\li53\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {based organizations (CBOs, PRIs) and
researchers.}\par\pard\li53\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100
{Conduct \uc1\u64257Xeldwork to obtain primary data through}\par\pard\li53\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {interviews and other participatory methods
to arrive at a}\par\pard\li53\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{comprehensive understanding of local models of TB and}\par\pard\li53\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {its treatment.}\par\pard\li53\ri0\sl-
320\slmult0 \fs20\cf2\f0\charscalex100 {Stakeholders\uc1\u8217X understanding of TB
and its treatment in}\par\pard\li53\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{the catchment area is enhanced.}\par\pard\li53\ri0\sl-333\slmult0
\fs18\cf2\f0\charscalex100 {Enhanced awareness of health and TB at community level.
}\par\pard\li53\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Existing baseline
data and anthropological and other}\par\pard\li53\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {relevant studies.}\par\pard\li53\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Oral accounts of health workers.}\par\pard\li53\ri0\sl-
320\slmult0 \fs20\cf2\f0\charscalex100 {Fieldwork in selected villages (individual
interviews,}\par\pard\li53\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {focus
group discussions, key informant interviews with TB}\par\pard\li53\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {(current and former) patients, their
families, traditional}\par\pard\li53\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{healers and PRI members).}\par\pard\li53\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Unavailability of reliable up-to-date
data.}\par\pard\li53\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Unavailability
of competent researchers.}\par\pard\li53\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Lack of time and funding for
research.}\par\pard\li53\ri0\sl-360\slmult0 \fs20\cf2\f0\charscalex100 {Detailed
descriptive account of illness perceptions and}\par\pard\li53\ri0\sl-240\slmult0
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of}\par\pard\li53\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {target groups in
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\fs18\cf0\par\pard\li1360\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{20}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf2\f0\charscalex100 {Accessing TB
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1}}}}\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\margtsxn666\margbsxn93\pard\li
413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-413\slmult0
\fs22\cf2\f0\charscalex100 {The four baseline studies in this volume were
commissioned speci\uc1\u64257Xcally for}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {enhancing an understanding of the local conditions to
guide the development}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{of the intervention. While the health status study provided
epidemiological}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {data
on prevailing illnesses, the community studies presented an in-
depth}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {account of
lifestyles, patterns of habitations, village life and the
operation}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {of the
health system at the grass-roots level. Similarly, the study on
access}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {discussed how
social distance in\uc1\u64258Xuenced people\uc1\u8217Xs health-seeking behaviour
and}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {service
delivery. The in-depth study on the functioning and living
conditions}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {of
health DOT providers in Malkangiri provided detailed information
on}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {planning the
initiative involving recruitment and training of a corps of
local}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {DOT providers
at village level. However, it would not be necessary to
conduct}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {research to
the same extent in other areas once the model has been
developed}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {and
consolidated. More basic PRA (participatory rapid appraisal) tools can
be}\par\pard\li413\ri0\sl-306\slmult0 \fs22\cf2\f0\charscalex100 {used to
\uc1\u64257Xne-tune the model to local conditions.}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-400\slmult0
\fs24\cf5\f0\charscalex100\b {Step 4:}\b0 \fs24\cf4\f0\charscalex100\b
{ Government-NGO interface}\b0
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360\slmult0 \fs20\cf2\f0\charscalex100 {Resources}\par\pard\li520\ri0\sl-
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{indicators}\par\column\pard\li0\ri0\sl-400\slmult0 \fs20\cf2\f0\charscalex100
{Develop partnership with local NGO(s) to fund and}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {execute the project.}\par\pard\li0\ri0\sl-
333\slmult0 \fs20\cf2\f0\charscalex100 {State TB Cell, district-level health
authorities, NGOs.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-
360\slmult0 \fs20\cf2\f0\charscalex100 {Detailed discussions between government and
NGO}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {partners on
division of work, respective roles and}\par\pard\li0\ri0\sl-240\slmult0
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funding.}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100 {Document
specifying how project will be implemented,}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {who will do what and how project will be
\uc1\u64257Xnanced.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100
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333\slmult0 \fs20\cf2\f0\charscalex100 {Level of expressed
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cooperation among stakeholders.}\par\pard\li0\ri0\sl-333\slmult0
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1}}}}\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\margtsxn666\margbsxn106\pard\l
i413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-413\slmult0
\fs22\cf2\f0\charscalex100 {Formal documentation should seal the agreement between
partners either in}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{the form of a contract or at least a memorandum of understanding (MOU).
This}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {is the ideal
time to expand the base of stakeholders (if it has already not
been}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {done) by
including panchayat institutions, self-help group (SHG)
presidents}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {and
executive secretaries and other in\uc1\u64258Xuential persons of the area, who
could}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {provide
support and increase local ownership. Convergence with other
agencies}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {and
programmes in the area can considerably enhance the effectiveness
of}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {the intervention.
Drawing upon experiences gained in malaria control, polio}\par\pard\li413\ri0\sl-
293\slmult0 \fs22\cf2\f0\charscalex100 {eradication or leprosy elimination could be
helpful.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
400\slmult0 \fs24\cf5\f0\charscalex100\b {Step 5:}\b0 \fs24\cf4\f0\charscalex100\b
{ Budget}\b0
\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\cols2\c
olno1\colw2306\colsr-0\colno2\colw5893\pard\li520\ri0\sl-440\slmult0
\fs20\cf2\f0\charscalex100 {Activity}\par\pard\li520\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Responsible}\par\pard\li520\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {person/institution}\par\pard\li520\ri0\sl-
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{Outcome}\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
413\slmult0 \fs20\cf2\f0\charscalex100 {Resources}\par\pard\li520\ri0\sl-
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{Risks}\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
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{indicators}\par\column\pard\li0\ri0\sl-440\slmult0 \fs20\cf2\f0\charscalex100
{Funding for the community DOTS project in target area.}\par\pard\li0\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {State TB Cell and District Health Society.
The Government}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {of
India (GOI) may also fund development and research}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {aspects.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Identifying budget heads like salaries, transport,
training}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {workshops and
materials.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Identifying
sources of funding.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{Planned activities are matched with available resources for}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {successful implementation of the
project.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Resources
derived from involved agencies, e.g. health}\par\pard\li0\ri0\sl-240\slmult0
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SHGs\uc1\u8217X}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{contribution, etc.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{Involved costs not realistically assessed.}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Inadequate \uc1\u64257Xnancial resources to implement
the project.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Realistic
budget matching project activities.}\par\pard\li0\ri0\sl-320\slmult0
\fs20\cf2\f0\charscalex100 {Resources available for implementing
project.}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
3\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-426\slmult0
\fs22\cf2\f0\charscalex100 {In addition to funding from the tribal action plan of
RNTCP and partner NGO, }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {other sources of possible funding are district health
societies and the health }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {fund of local }\fs20\cf2\f0\charscalex100 {panchayats.
By this time the project is ready for implementation. }\par\pard\li413\ri0\sl-
293\slmult0 \fs20\cf2\f0\charscalex100 {Partnering agencies have a clear idea of
their respective functions; mechanisms }\par\pard\li413\ri0\sl-293\slmult0
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worked out; and adequate }\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {funding is available to undertake project for a
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{ Recruitment of tribal area supervisors (TASs)}\b0
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{Identi\uc1\u64257Xcation of tribal area supervisors (TAS) based on
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{criteria such as local residence, educational level and
mobility.}\par\pard\li0\ri0\sl-386\slmult0 \fs18\cf2\f0\charscalex100 {RNTCP and
GHS staff, NGOs, other stakeholders (CBOs, PRIs).}\par\pard\li0\ri0\sl-
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\fs18\cf0\par\pard\li0\ri0\sl-440\slmult0 \fs20\cf2\f0\charscalex100 {Development
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\fs20\cf2\f0\charscalex100 {Appointment of TASs through direct recruitment
undertaken by}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{stakeholders in collaboration. Administratively, TASs may be}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {contracted through local
NGO.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Suitable
candidates with ability and willingness to function}\par\pard\li0\ri0\sl-
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and the people are}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{appointed, and their terms of reference and area of
operation}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {clearly
de\uc1\u64257Xned.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
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vehicle, monthly}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{vehicle maintenance and transport allowance.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Unavailability of competent persons to occupy position
from local}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{area.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Unavailability
of funds to compensate required number of TASs.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Competent persons appointed as TASs with well-
de\uc1\u64257Xned areas of}\par\pard\li0\ri0\sl-240\slmult0
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\fs22\cf2\f0\charscalex100 {In the Malkangiri intervention the TASs were appointed
by an NGO. Their areas }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {of operation were determined on the basis of their
place of residence, location }\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {of nearest PHI and delineation of the geographical area
of responsibility. The }\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {TAS reduces the impact of physical distance by
connecting a range of key }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {functionaries and volunteers, including the district TB
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\fs20\cf2\f0\charscalex100 {community DPs, the LT with the pharmacist or the
volunteer at the SCC, and }\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {patient with community DP (see Steps 9 and 10). He can
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he }\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {can link up
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\fs16\cf2\f0\charscalex100 {The Malkangiri model for community DOTS programme in
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440\slmult0 \fs20\cf2\f0\charscalex100 {Responsible person/}\par\pard\li520\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {institution}\par\pard\li520\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {Process}\par\pard\li520\ri0\sl-
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413\slmult0 \fs20\cf2\f0\charscalex100 {Resources}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
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\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
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{Risks}\par\column\pard\li0\ri0\sl-440\slmult0 \fs18\cf2\f0\charscalex100 {To
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{quali\uc1\u64257Xed resource persons and institutions.}\par\pard\li0\ri0\sl-
386\slmult0 \fs18\cf2\f0\charscalex100 {Two-day workshop organized by DTO and NGO
in}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {collaboration with
external resource persons.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {TASs understand how to perform all duties under
their}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{responsibility.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{Training venue.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100
{Facilitator and necessary resource persons.}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Overhead projector, \uc1\u64258Xip chart,
stationery.}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100 {Training
module for community DOT providers using}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {pictorial treatment card (Annex
1).}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Flip book: A
special training course for community DOT}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {providers (pictorial treatment
card).}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Pictorial IEC
folder.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Pictorial
treatment cards for all categories of patients.}\par\pard\li0\ri0\sl-320\slmult0
\fs20\cf2\f0\charscalex100 {Sputum containers.}\par\pard\li0\ri0\sl-333\slmult0
\fs18\cf2\f0\charscalex100 {RNTCP microscope and slides.}\par\pard\li0\ri0\sl-
333\slmult0 \fs20\cf2\f0\charscalex100 {Medicine boxes for all categories of
patients.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Facilitators
and resource persons experienced with}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {community DOTS in tribal areas and/or use of
pictorial}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {card not
available.}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn
133\pard\li520\ri0\sl-386\slmult0 \*\tx2586\fs20\cf2\f0\charscalex100 {Assessment
indicators}\tab \fs20\cf2\f0\charscalex100 {Level of understanding among TASs of
how to perform}\par\pard\li2586\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {all
duties under their responsibility.}\par\pard\li3746\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-346\slmult0 \fs16\cf4\f0\charscalex100
{24}\par\pard\li2386\ri0\sl-186\slmult0 \fs16\cf2\f0\charscalex100 {Accessing TB
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District}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
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STLS.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Training
materials and equipment for SCCs: sputum cups, slides,}\par\pard\li0\ri0\sl-
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\fs20\cf2\f0\charscalex100 {Time to learn proper slide preparation is
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preparation.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Well-
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etc.}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\pa
rd\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-400\slmult0
\fs22\cf2\f0\charscalex100 {Steps 9 and 10 establish the infrastructure to enable
symptomatic cases to}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{undergo sputum examination without having to make the long and
\uc1\u64257Xnancially}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
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giving sputum. The TAS ensures smooth coordination between}\par\pard\li413\ri0\sl-
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patient. Once patients begin to be}\par\pard\li413\ri0\sl-293\slmult0
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LT, will assign a community DP from}\par\pard\li413\ri0\sl-306\slmult0
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village. Therefore, a corps}\par\pard\li413\ri0\sl-293\slmult0
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identi\uc1\u64257Xed and trained.}\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-400\slmult0 \fs24\cf5\f0\charscalex100\b {Step
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413\slmult0 \fs20\cf2\f0\charscalex100 {Selection of local community DPs in target
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TAS.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Un\uc1\u64257Xt
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persons identi\uc1\u64257Xed in}\par\pard\li2586\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {accordance with selection
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400\slmult0 \fs22\cf2\f0\charscalex100 {The principal role in the selection of
local candidates to take on the role}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {of community DPs would fall on the TAS. It may require
good interpersonal}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{communication skills to persuade a suitable person to take up this task on
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386\slmult0 \fs24\cf5\f0\charscalex100\b { Step 12: }\b0
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on}\par\pard\li200\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {signs and
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\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
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413\slmult0 \fs20\cf2\f0\charscalex100 {Risks}\par\column\pard\li0\ri0\sl-
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\fs18\cf0\par\pard\li0\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {Suitable
venue.}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100 {TAS and
additional resource persons, if possible.}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Refreshments and lunch.}\par\pard\li0\ri0\sl-
333\slmult0 \fs20\cf2\f0\charscalex100 {Training materials suited to non-
literate/neo-literate}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{persons: Training module for community DOT providers}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {using pictorial treatment card (to help
facilitator)}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {(Annex
1);}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Flip book: A
special training course for community DOT}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {providers (pictorial treatment
card);}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100 {Pictorial IEC
folder;}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Pictorial
treatment cards for all categories of patients;}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {One large pictorial treatment card in
vinyl;}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Sputum
containers;}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100 {Medicine
boxes for all categories of patients.}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Travel from residence to venue may delay
participants}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {and
shorten training session.}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Ineffective training (contents not suited to non-
neo-}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {literate persons
or does not meet local
needs).}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133
\pard\li520\ri0\sl-333\slmult0 \*\tx2586\fs20\cf2\f0\charscalex100 {Assessment
indicators}\tab \fs20\cf2\f0\charscalex100 {Suf\uc1\u64257Xcient number of
community DPs trained.}\par\pard\li2586\ri0\sl-320\slmult0
\fs20\cf2\f0\charscalex100 {Community DPs understand basic information
about}\par\pard\li2586\ri0\sl-240\slmult0 \fs18\cf2\f0\charscalex100 {TB, how to
provide and supervise treatment, \uc1\u64257Xll the}\par\pard\li2586\ri0\sl-
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{irregularity of treatment, counsel patients and refer}\par\pard\li2586\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {symptomatic cases.}\par\pard\li413\ri0\sl-
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{Since a large number of community DPs are likely to be non-literate or
have}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {limited
education, it is imperative that training materials and session
are}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {tailored to
meet their learning needs. While holding a writing
implement}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {like a
pencil can be very empowering, hesitation and dif\uc1\u64257Xdence of
older}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {non-literate
persons when faced with reading and writing tasks should
not}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {be
underestimated. National literacy mission functionaries and local
NGOs}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {engaged in
literacy work can be important resource persons for the
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1}}}}\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\margtsxn666\margbsxn106\pard\l
i413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-413\slmult0
\fs22\cf2\f0\charscalex100 {Facilities for treatment like functional SCCs and
availability of trained}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {community DPs should be in place before IEC activities
are started so that}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{suspected cases have access to treatment. Awareness generation on TB in
the}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {community,
especially through the involvement of local in\uc1\u64258Xuential
persons}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {like
educated youth (especially adolescent girls), ward members,
traditional}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {healers,
SHG members, teachers and students, has greater impact than
other}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {traditional
methods of posters or communication by health workers.}\par\pard\li413\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-400\slmult0
\fs24\cf5\f0\charscalex100\b {Step 13:}\b0 \fs24\cf4\f0\charscalex100\b { Local
IEC campaign on TB}\b0
\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\cols2\c
olno1\colw2586\colsr-0\colno2\colw5613\pard\li520\ri0\sl-440\slmult0
\fs20\cf2\f0\charscalex100 {Activity}\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
440\slmult0 \fs20\cf2\f0\charscalex100 {Responsible person/}\par\pard\li520\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {institution}\par\pard\li520\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {Process}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
320\slmult0 \fs20\cf2\f0\charscalex100 {Outcome}\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-413\slmult0 \fs20\cf2\f0\charscalex100
{Resources}\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{Risks}\par\column\pard\li0\ri0\sl-440\slmult0 \fs20\cf2\f0\charscalex100
{Awareness generation about TB, signs and symptoms,}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {availability of free and effective
treatment and location}\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf2\f0\charscalex100
{of nearest SCC.}\par\pard\li0\ri0\sl-386\slmult0 \fs18\cf2\f0\charscalex100 {TAS
with support from Block Extension Educator (BEE)}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {and in collaboration with CBOs, PRIs,
etc.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Context-
speci\uc1\u64257Xc IEC in local language, such as}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {community meetings and street
theatre.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Dissemination
of pictorial IEC folder.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {IEC activities undertaken in target area to
enhance}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {awareness
about TB and its treatment.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Pictorial IEC folder.}\par\pard\li0\ri0\sl-
333\slmult0 \fs20\cf2\f0\charscalex100 {Local street theatre
troupe.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {IEC messages
not tailor-made to local
needs.}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\
pard\li520\ri0\sl-386\slmult0 \*\tx2586\fs20\cf2\f0\charscalex100 {Assessment
indicators}\tab \fs20\cf2\f0\charscalex100 {Completion of successful IEC campaign
in target}\par\pard\li2586\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{area(s).}\par\pard\li2586\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100 {Awareness
about signs of TB, its curability and}\par\pard\li2586\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {availability of free
treatment.}\par\pard\li2586\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100
{Stigmatization of the disease (if existing) has been}\par\pard\li2586\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {decreased.}\par\pard\li2586\ri0\sl-
333\slmult0 \fs20\cf2\f0\charscalex100 {Increase in voluntary reporting of chest
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{ Awareness generation through IPC by community}\b0 \par\pard\li413\ri0\sl-
306\slmult0 \fs24\cf4\f0\charscalex100\b {DPs}\b0
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413\slmult0 \fs20\cf2\f0\charscalex100 {Resources}\par\pard\li520\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {Risks}\par\pard\li520\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Assessment}\par\pard\li520\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {indicators}\par\column\pard\li0\ri0\sl-426\slmult0
\fs20\cf2\f0\charscalex100 {Awareness generation about TB, signs and
symptoms,}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {availability
of free and effective treatment and location of}\par\pard\li0\ri0\sl-240\slmult0
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400\slmult0 \fs20\cf2\f0\charscalex100 {Community DPs with support of
TAS.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-440\slmult0 \fs20\cf2\f0\charscalex100 {Community DPs
interact with fellow villagers to spread}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {information on TB and availability of treatment at
public}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {places and
through household visits.}\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {People with cough of more than three weeks\uc1\u8217X
duration come}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {forward
for sputum examination.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100
{IEC materials like pictorial folders, posters and pamphlets.}\par\pard\li0\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {Not all community will be effective IPC
agents.}\par\pard\li0\ri0\sl-386\slmult0 \fs20\cf2\f0\charscalex100 {Increased
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333\slmult0 \fs20\cf2\f0\charscalex100 {Better understanding of TB as a disease and
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it.}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\par
d\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-426\slmult0
\fs22\cf2\f0\charscalex100 {In addition to direct supervision of medication
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\fs20\cf2\f0\charscalex100 {treatment card, an important task of community
DPs is to disseminate}\par\pard\li413\ri0\sl-306\slmult0
\fs22\cf2\f0\charscalex100 {information about TB and its treatment in their
respective communities. }\par\pard\li413\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li413\ri0\sl-386\slmult0 \fs24\cf5\f0\charscalex100\b {Step
15:}\b0 \fs24\cf4\f0\charscalex100\b { Documentation}\b0
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records.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Lack of
initiative of responsible persons/institutions to document}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {process.}\par\pard\li0\ri0\sl-
333\slmult0 \fs20\cf2\f0\charscalex100 {Unavailability of suitable
documenter.}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100 {Detailed
chronological account of the intervention, its planning,}\par\pard\li0\ri0\sl-
240\slmult0 \fs20\cf2\f0\charscalex100 {successes, failures and lessons
learnt.}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133
\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-400\slmult0
\fs22\cf2\f0\charscalex100 {The current outline of a strategy for community DOTS
intervention has been}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100
{based on careful documentation by external researchers of the
Malkangiri}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{initiative. It is important to continue documenting both the process
and}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {lessons learnt
for it to take on the form of a full-\uc1\u64258Xedged strategy that can
be}\par\pard\li413\ri0\sl-293\slmult0 \fs22\cf2\f0\charscalex100 {used in other
tribal areas in and outside Orissa}\par\pard\li413\ri0\sl-213\slmult0
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\fs20\cf2\f0\charscalex100 {institution}\par\pard\li520\ri0\sl-333\slmult0
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\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li520\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li520\ri0\sl-
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{Outcome}\par\column\pard\li0\ri0\sl-413\slmult0 \fs20\cf2\f0\charscalex100
{Monitoring the impact of the initiative and follow-up as
required.}\par\pard\li0\ri0\sl-320\slmult0 \fs18\cf2\f0\charscalex100 {State TB
Cell, DTO, STS, TAS and NGOs.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-386\slmult0
\fs20\cf2\f0\charscalex100 {Recording new case detection, treatment completion,
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default and retrieval rates.}\par\pard\li0\ri0\sl-333\slmult0
\fs20\cf2\f0\charscalex100 {Periodic assessment of performance of community
DPs.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {TB put regularly
on the agenda of the village}{ }\fs20\cf2\f0\charscalex100 {panchayat and
gram}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100 {sabha meetings
attended by RNTCP and NGO staff with periodic}\par\pard\li0\ri0\sl-240\slmult0
\fs20\cf2\f0\charscalex100 {data to support discussion.}\par\pard\li0\ri0\sl-
320\slmult0 \fs20\cf2\f0\charscalex100 {Mechanism for ongoing monitoring and
follow-up is
established.}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrs
xn133\pard\li520\ri0\sl-333\slmult0 \*\tx1706\fs20\cf2\f0\charscalex100
{Resources}\tab \fs20\cf2\f0\charscalex100 {Time and commitment of stakeholders,
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{Outcome}\par\pard\li520\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{indicators}\par\column\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100
{Initial enthusiasm may fade and pace of work may slacken at
all}\par\pard\li0\ri0\sl-240\slmult0 \fs20\cf2\f0\charscalex100
{levels.}\par\pard\li0\ri0\sl-333\slmult0 \fs20\cf2\f0\charscalex100 {Increased
voluntary reporting.}\par\pard\li0\ri0\sl-320\slmult0 \fs20\cf2\f0\charscalex100
{Short-term increase in susceptible cases.}\par\pard\li0\ri0\sl-333\slmult0
\fs18\cf2\f0\charscalex100 {Widely accessible DOTS
services.}\par\pard\li2040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2040\ri0\sl-
346\slmult0 \fs16\cf4\f0\charscalex100 {32}\par\pard\li680\ri0\sl-186\slmult0
\fs16\cf2\f0\charscalex100 {Accessing TB Services in a Tribal
District}\par\pard\sect\sectd\sbknone\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn13
3\pard\sect\sectd\sbkpage\pgwsxn9000\pghsxn12960\marglsxn666\margrsxn133\margtsxn66
6\margbsxn93\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
413\slmult0 \fs22\cf2\f0\charscalex100 {The above steps describe a process involved
in an attempt to set in place a}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {mechanism to increase access to RNTCP services in one
of the poorest and}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100
{least developed tribal districts of India. The success of such an
initiative}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {depends
on close networking between a large number of stakeholders.
Unlike}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {polio and
leprosy, TB is not a condition that will be eradicated or
eliminated}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {in any
foreseeable future. However, modern antibiotics offer the
possibility}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {of
complete cure. But managing that treatment regimen is a complex
issue}\par\pard\li413\ri0\sl-306\slmult0 \fs20\cf2\f0\charscalex100 {involving
sustained interaction between the patient, the community and
the}\par\pard\li413\ri0\sl-293\slmult0 \fs20\cf2\f0\charscalex100 {medical system.
While TB is the main focus of the current intervention, it}\par\pard\li413\ri0\sl-
306\slmult0 \fs20\cf2\f0\charscalex100 {should be developed further to also address
other priority health problems in}\par\pard\li413\ri0\sl-293\slmult0
\fs20\cf2\f0\charscalex100 {the intervention area. In that case, this would require
additional training of}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {community DPs to prepare malaria slides and give
malaria treatment and to}\par\pard\li413\ri0\sl-293\slmult0
\fs22\cf2\f0\charscalex100 {give vitamin and mineral
supplements.}\par\pard\li413\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li413\ri0\sl-
386\slmult0 \fs20\cf2\f0\charscalex100 {The remaining part of this volume presents
the baseline studies that guide the}\par\pard\li413\ri0\sl-306\slmult0
\fs20\cf2\f0\charscalex100 {development of the model, as well as the actual
implementation