Current Urban Studies
2013. Vol.1, No.4, 139-147
Published Online December 2013 in SciRes (http://www.scirp.org/journal/cus) http://dx.doi.org/10.4236/cus.2013.14015
Open Access 139
Exploring the Roles, Practices and Service Delivery
Mechanism of Health Service Providers Regarding
TB in Two Urban Slums of Dhaka
Enamul Hasib1, Tariq-Ul-Hassan Khan2, Malabika Sarker1, Shayla Islam3,
Akramul Islam3, Ashaque Husain4, Sabina Faiz Rashid1
1James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
2Water Aid Bangladesh, D h a k a , Bangladesh
3Health Nutrition and Populat i on Programme, BRAC, Dhaka, Bangladesh
4National Tuberculosis Con t rol Program, Dhaka, Bangladesh
Received September 24th, 2013; revised October 25th, 2013; accepted November 3rd, 2013
Copyright © 2013 Enamul Hasib et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Tuberculosis (TB) is a major health care burden in developing countries. With a high number of popula-
tion living in an environment with high congestion, controlling TB in Bangladesh especially in urban ar-
eas has been a big challenge. The current study aims to identify the perception and treatment practice of
formal and informal health service providers regarding TB in terms of treatment, referral system and to
find out the partnership mechanism and also community perception and their health seeking behavior in
two urban slums of Dhaka city. This is a cross-sectional study utilizing mixed methods approach and was
conducted in two urban slums, namely, Slum A and Slum B of Dhaka city. Health service providers both
formal and informal, community people and TB patients were selected as study population. In the quanti-
tative part a survey was carried out where all the existing health service providers were interviewed.
These health service providers were identified through 12 PRA (Participatory Rapid Appraisal) Social
Mapping. Seven Focus Group Discussions (FGD) were conducted with this community. Popular Health
service providers were identified through PRA matrix ranking during the FGDs and were selected for
in-depth interview. TB patients were identified during FGD for in-depth interview. Community in urban
slums is well aware of the infectious, contagious characteristics of TB. However, the long duration of
DOTS program has been a major cause of high rate of drop-out. Generally drug sellers, traditional healers,
homeopath and allopath (MBBS) practitioners are the primary point of contact of TB patients. They know
where to refer to diagnosis and treatment. The referral system based on informal relationship sometimes
leads to referring patients to wrong service providers. The mechanisms of TB programs in urban areas of
Bangladesh should seriously consider arranging regular training and monitoring of health workforce, set-
ting up formal partnership between formal and informal health service providers and generate information
that policy-makers could use to scale up TB control program.
Keywords: Tuberculosis; Health Service Provider; Partnership
Introduction
Tuberculosis (TB) is a major health care burden in develop-
ing countries (Ravichandran, 2004). It is reported as the second
highest cause of death from infectious disease after HIV/AIDS
in the world. Incidence of TB cases has steadily declined in
western and central Europe, North and South America, and the
Middle East. But there has been striking unexpected increase in
countries of the former Soviet Union, South Asia and in Sub-
Saharan Africa (Frieden, Sterling, Munsiff, & Dye, 2003). Al-
though, Sub-Saharan Africa has the highest incidence rate (290
per 100,000 population), the majority of patients with TB live
in Bangladesh, China, India, Indonesia and Pakistan where it is
concentrated among densel y populated areas (Dye, 2006). TB is
a major health concern in Bangladesh. Even though, it is a cur-
able disease, it has the highest rate of adult mortality in Bang-
ladesh. The urban population of Bangladesh is growing at an
annual rate of 5% - 6% which soon will be 40% of the total
population. The population of Dhaka city is approximately 12
million (Banglapedia, 2006) and about 30% of the population
live in slums and temporary squatter settlements without any
access to basic primary health care services ((DGHS, NTP,
2009; ICDDR, B WP 142, 2000). Slums are vulnerable due to
poor living conditions and are not recognized by government as
“legal settlers”. The overcrowding, poor ventilation and unhy-
gienic living conditions in slums favor the spread of TB. David
et al. (2007) found that children living in a squatter settlement
are 9 times more likely to have TB than non squatter children in
one of the Asian developing countries. David et al. (2007) also
described that gender is major cross cutting determinant of
health inequality. Poor urban women generally exhibit higher

E. HASIB ET AL.
risks for diseases and poorer overall health status than poor
urban men (David et al., 2007). According to the TB case noti-
fication report submitted to the WHO, about twice as many
men as women were notified as TB patients (WHO, 2008). The
prevalence of TB is comparable between males and females
until the age of 15 years, and then disparity starts. But TB pro-
gresses from infection to active disease much faster in women
during their reproductive ages than in similar age groups of
men. The gender differences in behavior may influence disease
progression (Karim, 2009).
NTP notified a total of 151,062 of all forms of TB cases
(104/100000 population) nationwide. 17.7% of them were re-
ported from urban areas. According to the WHO Report 2005, a
total of 7556 new smear positive, 1134 relapse, 4986 smear
negative pulmonary, and 2689 extra-pulmonary TB cases were
found and a treatment success rate of 76% was achieved in the
metropolitan areas (Dhaka, Chittagong, Khulna, & Rajshahi)
which was 15% lower than that of the upazilas (91%). Detec-
tion rates are particularly problematic among urban poor
women living in slum settlements and there are a large number
of TB patients who seek treatment from private sector and in-
formal providers. It is important to acknowledge that most pri-
vate sector health personnel and informal providers are not
officially part of the formal government health system, and
therefore do not follow NTP guidelines. This can reduce the
efficacy of TB services received by patients and discourage the
accuracy of NTP statistics on the TB situation, with an in-
creased potential for drug-resistant TB in Bangladesh (TB Pol-
icy in Bangladesh, Public Health Watch, 2006). There have
been informal attempts for partnerships between the govern-
ment, NGO sector and informal/private sector, but coordinated
effort to create a national implementation strategy for engaging
private providers is absent (WHO, 2010). One challenge faced
by the partnership is balancing the needs for central level con-
trol and local responsiveness. Most of the time, decision mak-
ing at the central level creates delay in endorsing local level
activities formally. In this context, encouraging local staff to
work with NGOs to solve problem at the local level can be
difficult (Islam et al., 2011). The multiplicity of providers,
fragmented services, absence of appropriate coordination part-
ners, and insufficient coverage lead to gap and duplication in
treatment leaving the urban poor grossly underserved. Apart
from partnership, the challenge also lies in communication and
community initiatives for referral of suspects for case detection
in the urban areas (Islam et al., 2011). Informal partnership and
relationship among the local level informal health service pro-
viders in urban slums of Dhaka has not been discussed much in
previous studies and hence, a gap in literature is found which
created the scope of this study.
The current study aims to find out the partnership mechanism
among the range of formal and informal health services provid-
ers and to explore health seeking behavior of slum communities
suffering from TB.
The government of Bangladesh has shown its commitment to
control TB by establishing the National Tuberculosis Control
Programme (NTP). In 1994, BRAC and the National Tubercu-
losis Program (NTP) formalized their relationship to enable
coordination on a large scale in anti-TB care. The Global Funds
to Fight AIDS, TB and Malaria (GFATM) project has helped
smaller local NGOs to offer TB control services (model of
community-based DOTS) all over the country in an effective
and cost-effective manner (TB Policy in Bangladesh, Public
Health Watch, 2006). Launched 2002, the Global Fund to Fight
AIDS, TB, and Malaria (Global Fund) represents a surge in
dedicated resources for TB. In 2004, the national partnership
for TB control included 10 NGOs, including BRAC, imple-
menting TB services. In 2011, there are 44 institutions working
on TB control, including several non-implementing partners
that provide technical support and operational research (Bang-
ladesh CCM, 2009: 41). The DOTS coverage by BRAC is more
intense and organized in rural areas than the urban areas. Be-
cause many urban patients sought care from private practitio-
ners or drug sellers, BRAC reached out to these private practi-
tioners and provided education about TB diagnosis and treat-
ment and encouraged referrals of TB patients to BRAC and
government facilities. By the end of 2007, according to Islam et
al., (2011) BRAC covered a catchment area of 3.2 million in
Dhaka, including those covered by the 18 peri-urban centers,
and had diagnosed over 3100 cases of TB.
Methodology
Study Desi gn
This is a cross-sectional study utilizing mixed methods ap-
proach. The study has three components, first: a social mapping
of health providers to identify the providers’ engage in provid-
ing TB treatment or referral, second: a quantitative survey of
the health providers identified through social mapping, and
third: Focus Group Discussion (FGD) with community and
qualitative interview with health providers, key informants and
clients. Through 12 social mapping with the community people,
53 service providers including both formal and informal who
are providing anti-tuberculosis care were identified and were
taken study population for the quantitative survey. Later focus
group discussions and in-depth interviews were conducted as
part of qualitative component. In-depth interviews were carried
out with the TB patients were identified in the FGDs. 7 FGDs
with both men and women were carried out and 24 TB patients
were interviewed. The criteria for selecting TB patients was
people who have been diagnosed as TB, currently under any
form of TB treatment and/or have discontinued treatment but
not cured. Popular service providers were also identified in the
focus groups discussions and social mapping by community
groups, and were selected for in-depth interviews. 27 popular
health service providers were interviewed.
Study Site
BRAC provides TB related health care services in the peri-
urban area through BRAC Health Program and in the urban
slums through partner organizations. Two slums were selected
purposively in consultation with BRAC TB program; as study
sites based on long history of existence, performance in terms
of TB case notification rate (one selected slum is comparatively
low performing and another one is comparatively high per-
forming) and presence of long term interventions by BRAC and
partner organizations.
NGO operating in Slum A is NGO A and NGO B in Slum B.
The estimated total number of households in Slum A is 4098
with a total population of 16,380 (based on discussion with
NGO A and slum dwellers). Total household at Slum B is 2170
and population size 9350 (based on discussion with NGO B and
slum dwellers).
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Data Collection
Social mapping was carried out to identify the existing health
service providers. Slum A is divided into five parts and the
boundaries of the parts were identified with the help of the slum
dwellers. A total of 8 social mappings were done in Slum A.
Four social maps were drawn in Slum B. The participants of the
social mapping were asked to draw the geographical map of the
area. In every session one person from the participants was
identified to draw the map. They were asked to identify the
boundary of the respective area, roads, water sanitation facility,
bazaar, educational institute and place of practice and the
catchment area of the health service providers active in this area.
Thus a geographical map and a comprehensive list of health
service providers were developed. During conducting social
mapping, listing of all health service providers including both
formal and informal who are delivering health services in the
two selected slums were carried out. These providers range
from qualified allopathic doctors gaining MBBS degree from
different medical colleges, semi-qualified allopathic providers
that include providers who have received training of varying
duration from a formal institution in the public or private sector,
drug sellers most of whom have had no training in dispensing
drugs, traditional healers like Kabiraj whose practice is based
on diet and herbs, faith healers mostly providing spiritual
treatment etc. Apart from them there are NGO workers who
provide DOTS in the urban slum area. Then the survey was
conducted among them. The survey collected data on knowl-
edge, role, treatment practice of TB, partnerships if any and
referral linkages with other institutions/providers. Given that
the number of providers (formal and informal) available was
not too large, all providers listed were interviewed. A total of
29 service providers from Slum A and 24 from Slum B slum
were interviewed. Focus group discussions (FGD) with com-
munity were conducted to understand perception, stigma, gen-
der issues and the health seeking behavior regarding TB and
popularity of health service providers. 7 FGDs were conducted,
3 at Slum A and 4 at Slum B. Four FGDs were conducted with
men separately and 3 with women. In addition to asking com-
munities to rank popular health service providers, causes for
their popularity were also identified to understand reasons to
access certain providers over others. The PRA ranking exercise
was conducted in the following manner: participants were
asked to number—1) the health service providers on the basis
of their popularity and 2) the causes for their popularity sepa-
rately in a scale of 1 to 10 (10 being the most popular and 1
being the least). Flip-charts were used for doing the rankings,
note was taken and recorders were used for recording the dis-
cussion. Notes were taken in Bengali and the transcripts are
written also in Bengali followed by English translation for
analysis. After completing survey and FGD, in-depth inter-
views with selected health service providers were carried out.
Twenty seven (16 from Slum A and 11 from Slum B) health
service providers were selected purposively following a set
criterion for in-depth interview and the criteria for selection
were: popularity of the service provider among the community,
experience on delivering health service in the locale and diver-
sity of health service providers. In the in-depth interviews,
questions were asked on knowledge and perception of TB,
health service mechanism in terms of TB case detection, treat-
ment and referral, and the process whereby they have local
level partnership. Along with health service providers in-depth
information from TB patients of these two areas were also re-
corded for triangulation. TB patients were identified during
FGD. Criteria for selecting TB patients were active TB patients
currently undergoing any form treatment, treatment drop-out
and cured from the disease. A total of 24 (13 at Slum A and 11
at Slum B) TB patients were interviewed. All the notes were
taken in Bengali and also the detailed transcripts were written
in Bengali. Then these were translated into English for analysis
Before starting data collection, questionnaire and interview
guidelines were pretested and piloted, and necessary revision
and modification were carried out. The questions were stan-
dardized to ensure reliability, generalizability, and validity.
Data Analysis
Review and analysis of ongoing data found missing data in
some case which required clarifications. So the team members
went back to the field to collect more data, or repeated in-depth
interviews for clarifications. This process of review, update and
additional fieldwork was done throughout the research period.
Transcribed qualitative data were translated into English and
coded thematically for analysis. In every stage, quality was
controlled by the senior research team and supervisors. Thus
reliability and validity of data were ensured. Univariate and bi-
variate analyses of quantitative data were carried out to explore
the findings of survey with health service providers regarding
their background information, perception, knowledge, role,
treatment practice, training, referral, local level partnership.
Ethical Approval
Written informed consent was taken from all participants be-
fore the interview took place. The informed consent form in-
cluded all necessary information for the participants that was
read out at the beginning of every interview. It was maintained
strictly that there was no coercion during data collection. Par-
ticipants were informed that they were absolutely free to with-
draw from the study at any time even after giving their consent.
It was also mentioned that there was no direct benefit for par-
ticipants from the study. Confidentiality and anonymity of the
TB patients were given supreme priority.
Results and Discussion
A variety of private and informal institutions have been im-
plementing anti-tubercular care with differential effectiveness
in urban slum area of Bangladesh. These providers are qualified
medical doctors, allopathic practitioners who received short or
long term training from a public/private formal institution, drug
sellers most of whom have had no training in dispensing drugs,
traditional healers like Kabiraj whose practice is based on diet
and herbs, faith healers mostly providing spiritual treatment etc.
Apart from them there are NGO workers who provide DOTS in
the urban slum area. According to the survey conducted among
the 53 health service providers, 77% were male and 23% re-
spondents were female. Majority of the health service provider
(93%) had academic education while 7% had no academic edu-
cation. More than two third (69%) of the total respondents com-
pleted up to higher secondary education whereas, about one
fifth (22.4%) had graduate or post graduate level of education.
8.2% respondents passed from Madrasa (Arabic schooling sys-
tem). Among the health service provider majority i.e. 43% were
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E. HASIB ET AL.
drug seller (Pharmacy), 25% were NGO worker or Health As-
sistant or Midwife, 15% were homeopath, 7% were Spiritual
Healer, 6% were Allopathic, 2% herbalist, 2% were acre farm.
About two third (66%) of health service providers reported
having medical qualification while remaining one-third (34%)
had no such qualification. Of them 51.4% have RMP or PC or
LMAF degree, 20% have Paramedics or Midwife degree, 17%
have Diploma or Diploma in Medical Assistants degree, 11%
have Homeopath degree, 3% have MBBS, Medical Technolo-
gist degree.
Knowledge and Perception of TB
A number of varied beliefs and understandings on the causes
and spread of TB existed among providers and community peo-
ple in the two urban slums. These ranged from biomedical rea-
sons, environment conditions, to supernatural causation, and
social and economic factors. Gender, old age, mobility and life
style and behavior were also seen to contribute to TB. Most of
the service providers (informal and formal) reported that TB is
an infectious disease caused by bacteria. The risk factor of the
disease includes living in densely populated unhealthy and
polluted environment. It is known as TB and “Jakkha” in Ben-
gali. A drug seller of Slum A said, “If cough lasts for more than
2 - 3/4 weeks and doesn’t cure, then it can turn into TB”. About
half of the health service providers (49.1%) reported about TB
patient’s coughs or sneezes as routes of transmitting TB fol-
lowed by Unhygienic environment (Dust) (41.5%), From in-
fected (TB) person’s breathing (30.2%), getting cold/getting
cold long time (13.2%), polluted or dirty environment (5.7%),
density of people, damp environment (3.8%) etc. Besides, re-
spondents also reported smoking (43.4%), genetic disorder/
inherited (24.5%), alcohol/drug use (17%), eating from the
same plate (11.3%) etc. as the causes of transmission of tuber-
culosis. A common understanding among the respondents was
that this disease affected men more than women as they were
more mobile, and ate street food. One TB patient, aged 24
year’s male from Slum B shared, “If someone eats at restau-
rants, they can be affected by TB because a lot of people eat at
restaurants and it is not possible to know who among them
have TB and who have not. And thus TB can spread in restau-
rants while sharing same utensils”. Both health providers and
community people shared that life style factors such as smoking,
drug addiction and injury caused in lungs from smoking to-
bacco could lead to TB. Lack of nutritious food in the body also
played a role. Many health providers reported that by taking
full course of TB drugs, keeping away from unhygienic envi-
ronment, dirt and garbage one can prevent themselves from
getting infected by TB. Many also mentioned “quitting smok-
ing” as a way to prevent TB infection which is a wrong percep-
tion. A few of the respondents both providers and community
people shared that TB was a hereditary illness and could not be
avoided it if was in the family blood.
Polluted and Congested Environments
Many stated that TB occurred from staying in unhealthy and
unhygienic environments. Slums were seen to be very vulner-
able living spaces for the spread of TB. Slums tend to be
densely populated areas, congested, with little sanitation and
poor drainage systems in place which allow for the rapid spread
of disease. Some of them shared that open defecation may also
cause TB as this created an unhygienic environment. One par-
ticipant living in Slum B shared, “If someone throws waste
materials in front of house, the environment gets dirty. The
occurrence of this disease is higher among the slum dwellers
because they live a congested and dirty life, sometimes they
take their meal sitting on the same place where they defecate.
This is dirty environment”. In these overcrowded and congested
spaces, people stay close to TB patients, which is seen as vul-
nerability to the disease. Family members of a TB patient are
very likely to be affected by TB because they live very closely;
share bed, utensils, food; touch each other. Among the respon-
dents from community people, who stated that, TB is a conta-
gious disease; emphasized the importance of wearing masks
and using separate utensils to prevent TB infection. But some-
times masks are not very available in the neighborhood shops,
so that it is not always possible to wear mask and due to the
poverty sometimes using separate utensils is not always possi-
ble either.
Signs and Symptoms of TB
The survey data highlight that most of the service providers
(informal and formal) perceived that a persistent cough, which
lasted more than 3 weeks was TB. Three fourths of them re-
ported that cough that lasts longer than 3 weeks as signs and
symptoms of TB followed by coughing up blood (60%), fever/
fever at night/fever without clear reason persisting for more
than 7 days (58.5%). Fifty six percent said that cough/cough
that lasts for more than 1 week was TB and 47.2% mentioned
signs of weight loss, 32.1% mentioned ongoing fatigue/loss of
appetite, 17% mentioned chest pains and 11.3% mentioned
sweating at night. In the in-depth interviews and focus group
discussions, providers as well as community people also shared
similar types of perceptions on signs and symptoms, but a com-
mon understanding that differentiated from a simple cough, was
a lingering cough. However, among the respondents there was a
variation of knowledge in terms of number of days for cough-
ing that ranged from 7 to 30 days. Other signs included, cough-
ing up blood, losing weight, loss of appetite, suffering from
fever for more than one week, weakness, throat irritation at
initial stages etc. All the TB patients who were interviewed
mentioned TB as a terrible but curable disease. They mentioned
coughing and vomiting with blood, losing appetite and weight
as the symptoms of TB. A TB patient from Slum A explained,
“A TB patient loses his appetite (khudhamonda) so much that,
even drinking water might cause vomiting”. A TB patient start
losing body weight at a very quick rate and starts feeling weak
and sleepy all day. A TB patient from Slum A, 18 years of age,
male said, “When someone gets TB, it is very likely that he/she
will be affected with few other diseases like Jaundice, Typhoid,
fever cold etc.”.
Stigma
A number of respondents—both service providers and com-
munity people claimed that TB patients, irrespective of sex are
usually avoided and treated badly. In some cases, both provid-
ers and community people shared stories of women who were
abandoned by their husbands because of TB or some women
remain unmarriageable because they had suffered from TB.
There were stories about TB patients being isolated, discourag-
ing them from going to social gatherings, market places and
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E. HASIB ET AL.
deliberately avoiding any interactions with them etc. In some
extreme cases, it was reported that some families ended their
relationship with the patients. However, there was also a narra-
tive of a woman who was suffering from TB and her husband
was extremely supportive and didn’t abandon her. A few re-
spondents claimed that women were more vulnerable compared
to male patients, because of their lack of economic and social
power and they didn’t have control over when they could seek
treatment. According to many, in the past it was believed that a
TB patient was suffering because of their own “sin and curse”
which often placed a moral judgment on the person, but this
was slowly being replaced by blaming external factors, which
didn’t blame the individual for the illness. A male TB patient
from Slum B explained, “No, TB is not caused by having sin or
being cursed. Anyone can be affected by TB. However, people
who smoke biri-cigarettes have the greatest possibility of get-
ting the disease. Besides, those who have a reckless lifestyle,
live in dirty surroundings, take addictive substances or drugs
may also get TB”. However, despite these changes, fears and
superstitious beliefs continue. One respondent, 40 years old
male TB pat ient from Slum B said T B could spread by showin g
hatred towards a TB patient. He described, “Once I saw a
woman in front of Ajimpur Maternity. She coughed up blood
through nose and throat. Watching her I felt abhorrence. After
one week of that incident I got affected by that disease. I
watched that woman from a distance. I didn’t even touch her.
But I got affected by tuberculosis”. Many of the respondents
said that gender discrimination and stigma existed in the past
when they were younger and living in village but these were
less frequent in urban areas. However few of the female re-
spondents shared some of their experience regarding gender
and stigma. One female TB patient, 30 years of age from Slum
B shared, “When I had TB, my neighbors did not come to my
house, and I did not visit anyone. I spent most of the time in my
room, on my bed, and I felt depressed, as I felt that no one
came to my room because of my illness. Sometimes I thought I
have not committed any sin, so why did this happen to me?”
Interviews with women and men and providers found that in
many cases, females tend to hide their disease. They tolerate
fever, cough, pain until these become severe, as many cannot
afford to pay for treatment and often are too scared to seek
treatment. In addition, it was shared by both community people
and providers that females who had suffered from TB in the
past still faced challenges in getting married. A male drug seller
shared, “After proposing for marriage, if groom’s relatives
come to know that the bride suffered from tuberculosis earlier
then they don’t show further interest. They start looking for
another bride. They think that she may get affected in the future
too”. Health service providers argued that since treatment was
widely available now and people could be cured there was no
point in avoiding TB patients, keeping them isolated and can-
celing marriage proposals etc.
Health Services
The health care service in terms of TB in both Slum A and
Slum B involves providers like pharmacy based drug sellers,
MBBS doctors and paramedics, homeopath doctors, spiritual
healers, ayurveda and traditional healers, NGOs active in these
areas, diagnostic centers, government hospitals etc. Initially pa-
tients come with the complaints of fever and cough. Most of the
patients are residents of the slum. They prescribe them anti py-
retic and anti histamine drugs and sometimes antibiotics. If the
fever and cough are not subsided, moreover patient start losing
weights, then they take different approaches depending on their
type of practices. This finding is also evident in the survey data.
One-fifth of the health service providers provide case detection
(diagnosis of TB) service to the suspected TB positive cases.
Majority i.e. 83% of the health service provider reported that
they usually refer the suspected or diagnosed TB patients after
treating the patient for 2 - 3 weeks. Survey data revealed that
13% health service providers do not provide any TB related
health service. The initial treatment is given according to the
symptom of the patient. When these problems are not reduced
then the patients are referred to diagnostic center, hospital for
lab diagnosis of TB. Usually allopathic doctors either send
them to diagnostic centre for further evaluation or directly to
health facilities like TB hospitals or NGOs providing services
for diagnosis and treatment of TB. Drug sellers also refer pa-
tients to government hospitals or NGOs. NGO workers visit
door to door and inform people about satellite and static clinic.
If they find anyone with symptoms of TB or any diagnosed TB
patients, they send him/her to satellite clinic. Then depending
on diagnosis, patient is enrolled for treatment of TB. NGOs
also receive patients referred by the local health service provid-
ers be it allopathic doctor or drug seller. Once a patient who
goes to a NGO clinic, he get himself registered sees a doctor. If
the patient is diagnosed with TB, he has to fill out a TB patient
form and being given a card for collection of medicine. For
laboratory tests, poor patients are referred to government facili-
ties and those who can afford are referred to private clinics.
According to the service providers, patient prefer to go to pri-
vate diagnostic centers as they don’t have to wait long and they
receive proper service. Finally, it depends on the financial con-
dition of the patient whether he will go to a government hospi-
tal or a private facility. Mainly patients are sent there for cough
test and chest X-ray. In some cases, blood test (Mantoux Test)
is done. Homeopath doctors sometimes continue their treatment
even after the patient is diagnosed as TB patient. In some cases,
they claim, that patient came round. But when the treatment
fails and condition of patient keeps deteriorating, they refer
patients either to a government hospital or an NGO providing
treatment for TB. In that case, the patient is already in the ad-
vanced stage. One of the respondents quoted, “After taking
medicine for 90 days, cough test, blood test and X-ray are done.
If germ of TB is still identified then I provide a drug for 15 days.
Even after that if patients don’t get well, I suggest them to re-
ceive treatment from TB Hospital”.
Health Seeking Behavior
Primarily people in the slum seek treatment from the phar-
macy close to their residence or workplace when they have
fever, cough, and cold. Besides taking medicine from the phar-
macy, they also go through some home remedy like for fever,
they pour water on their head, wipe their body with wet cloths;
for cold, they take hot tea etc. while choosing health service
providers, people consider the closeness of the health service
providers from their residence, popularity, cost of treatment etc.
sometimes they choose the health service providers by their
own and sometimes they are referred by neighbor or relative
who have experience of seeking health service in the locality.
One TB patient from Slum A who is 35 years old male said, “In
the beginning I had light coughing and I thought the coughing
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E. HASIB ET AL.
was caused by the hot weather. The coughing started to in-
crease slowly and continued for about one week. Then I felt
that I was suffering from fever and went to the pharmacy near
the gate of Niketon. As it is close to my house I go there for
health service for any minor health problems. I brought medi-
cine for fever and coughing and took medicine for about 15
days. But when I was not getting well, I went to the TB hospital
according to the advice of my brother”. When the cough, fever,
cold are not cured by taking medicine from local facilities peo-
ple seek for other health facilities. Cost of treatment plays a
vital role in choosing health care service. People were mostly
found to be more relying on government hospital like TB Hos-
pital comparing to NGO facilities regarding TB treatment and
the local pharmacies also refer most of the TB patient to gov-
ernment hospitals rather than NGO facilities. The perception of
incurableness of TB has been changed probably due to more
and more availability of DOTS, treatment success and in-
creased awareness among the community. Respondents now
believe that a TB patient can completely come round if s/he
takes full course of medicine in right time from the Family
Health Centre or the City Health Centre, Surjer hasi Clinic
(CWFD), UTPS, BRAC Health Centre, TB hospital at Mohak-
hali. One 18 years old male TB patient from Slum A said, “The
doctor prescribes medicine according to the condition of the
patient. If the condition is severe, s/he might have to take medi-
cine for 6 months. If it’s less severe, then 4 months and if it is
the least severe, then 2 to 3 months of medicine can cure tu-
berculosis”.
Referral System
Near about three fourth (72%) health service providers re-
ported that they refer TB patients to a government health facil-
ity. In Slum B 46% health service providers noted that they
refer diagnosed or suspected TB patient to CWFD clinic DOTS
center while in Slum A 25% health service providers refer TB
patients to UTPS. Besides 10.9% health service providers refer
TB patients to a NGO health facility followed by 2.2% to
MBBS Doctor, 2.2% to Homeopath Practitioner. However, the
service providers at Slum A, also prefer to send their at BRAC
health facility Moddho Badda’ which is far from the slum. The
reason for preferring BRAC health facility is that there one
doesn’t have to be a victim of peddlers. The standard of treat-
ment is good here and all the treatment and medicine are given
free of cost. The caretakers come to the house of the patients
and make them take the medicine. TB hospital falls short to
BRAC health facility because people are reluctant to go to TB
hospital as they have to pay extra money to the staffs. Peddlers
are very active there. People do not want to go through the
hectic process the hospital. Female patients are also reluctant to
go to hospital as once they go there their physical conditions
will be revealed and will be known to many people. At the
same time, this is also true that TB hospital is an old institution,
a specialized institution for TB and well-known as it is close to
the neighbourhood. Many people prefer to go there as the
communication facilities is easier. Then again often the patients
have familiar staffs at the TB hospital. Many people do not
know about BRAC health facility or the UTPS. In Slum B, TB
symptomatic patients are being referred to TB hospital in Mo-
hakhali and Shyamoli, Sohrawardi hospital, and Smiling Sun
clinic of CWFD. Smiling Sun clinic is much preferred option as
most of the patients are being referred here. Smiling Sun visits
slum regularly. They arrange satellite clinic at slum on every
Wednesday. Sometimes people go to TB hospital at Mohakhali
for treatment. Later they are referred to Smiling Sun clinic be-
cause it is within the reach of the people of this area. One NGO
worker from Slum B mentioned, “Having treatment is easy. If
anybody can reach up to treatment centers, medicine is given
free which is a big opportunity for poor patients. All they have
to do is to go to the facility”. TB hospital is also in demand in
Slum B as this is a specialized hospital for tuberculosis. Having
reference from TB Hospital makes it easier to have medicine
from Surjer Hasi.
Follow-Up
Private services providers do not keep track of their patients,
as they do not have such system. However, since most of the
service providers live in the neighborhood, they know the pa-
tients personally. Some of the health service providers try to
keep track of the status of their referred patients informally. If
they visit a patient on call and if there is a TB patient in the
neighborhood, they visit him as well. Thus, service providers
stay connected with the patients. One of the drug sellers from
Slum A, aged 26 said, “As most of the patients are from this
area, I meet some of those patients when I move around”. This
connectivity sometimes helps them to identify patients who do
not complete treatment or course of medication. As the treat-
ment is long term, pa tients become rel uctant to take medicat ion
once they start getting well. Generally, women tend to complete
the treatment than men. They try to cure fast by taking drugs
regularly. Sometimes patients leave hospital on “risk bond” be-
cause it becomes difficult for them to stay at hospital for three
months. Many patients come from village and intend to stay for
5 - 10 days. This affects their treatment a lot. Some of these
patients are identified by the service providers in the commu-
nity and also by the NGOs. NGO clinics keep track of their
patients through field staff. They make sure that all the patients
are taking drugs properly and regularly. If someone leaves the
city and goes anywhere else then the patient is issued a card so
that he can receive medicine from the local health care center.
Challenges in Seeking Treatment
One of the common challenges found during receiving treat-
ment for TB was the lengthy nature of the treatment. Many
people start the treatment but stop it at the middle of the treat-
ment. One respondent, a TB patient of age 35 years from Slum
A who stopped taking medicine before completing the course
and didn’t resume the treatment explained, “They told me to
make the documents again. I work at garments factory. If I
would go for new documents, I had to spend 3 - 4 days and had
to miss office for those days. Salary for those days would be
deducted. That’s why I didn’t go for new documents”. TB pa-
tients have to go to Smiling Sun to collect the medicine every
day or twice a week which sometimes cause problem for them
to maintain regularly. Another male responded, a TB patient, 57
years of age from Slum A explained another problem that he
faced during taking TB treatment from UTPS, “The problem
that I faced is that I have to go daily to collect my medicine.
UTPS doesn’t give medicine in one lot. The biggest problem is
that there is no one there to administer the injections. Every
day I have to pay tk. 10 to a pharmacist elsewhere to get my
injection. If I miss an injection, I will be finished. If UTPS
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E. HASIB ET AL.
would push the injections, then I wouldn’t face this problem”.
Patients also discontinue treatment when they start feeling bet-
ter after taking medicine for few days. At one point they stop
taking medicine and eventually start suffering from TB again
and have to start treatment over again.
Partnership
Most of the service providers especially pharmacy based
drug sellers, private doctors, traditional and spiritual healers do
not have any formal partnership neither among themselves nor
with the hospitals and NGOs active in Slum A and Slum B area.
But in terms of informal partnership (which is more like a rela-
tionship than partnership), many of them maintain linkage with
other private service providers, diagnostic centers, NGOs and
employees of hospitals. Basically this partnership develops be-
cause of long term kinship, accessibility and presence in the
neighborhood. This informal partnership also develops between
individual service providers and NGOs and hospitals. At Slum
A, many service providers send patients to UTPS or TB hospi-
tal. Personal relationship with employees of NGO and hospital
plays role in such case. Patients also get benefit from this ar-
rangement as hospital employees take special care if patients
mention about a private service provider whom the hospital
employee knows well. One homeopath practitioner from Slum
A said, “I send patients to Dr. Borkotullah. If patients take my
name to him then he pays more attention. In case the patient is
poor, sometimes he provides sample drug if it’s available”.
Another reason for sending patients to NGOs is that they may
get selected for training. This informal partnership mostly does
not involve any financial benefit unless this is with any com-
mercial diagnostic centers or private clinic. Sometimes part-
nership develops only because of the goodwill of the provider.
Drug sellers at the pharmacy send patients to NGOs active in
their neighborhood. Field workers form NGOs also visit phar-
macy, private doctors and request them to send patients who
have TB symptoms there. They also inform service providers
about treatment of TB and inform them that cough tests are free
of cost. They give them leaflets of their organizations. Some-
times private service providers send patients to diagnostic cen-
ters for cough test instead of sending them to some NGOs
where cough test is free. The reason behind this is they get
financial benefit by sending them to a commercial facility.
Working in partnerships can improve appropriate and timely
referral system among the service providers. On young allopath
practitioner from Slum B mentioned, “I passed MBBS in 2007.
I have been working here for the last five years and now realize
that if we all work together, we will be surely successful. Drugs
and tests are free but we have only one problem; we have been
failed to make our management system efficient”.
The Role of NGO and Other Actors in Preventing TB
NGO and service delivery organizations promote timely ac-
cess and treatment of TB, and the use of face masks among TB
patients to avoid the spread of infections. However, this out-
ward use of mask was challenging for many of the patients, as
they were made fun of and it was an obvious “marker” of being
an infected patient. According to the respondents both health
providers and TB patients, this happened due to superstitions,
lack of education and social awareness. They argued that the
situation could be improved if staffs from the government hos-
pital, members of the community, NGOs like BRAC, and doc-
tors and nurses come forward to speak freely on TB, which
contribute to promoting understanding and awareness, remove
stigma and create sympathy for patients. According to a ho-
meopath practitioner from Slum A, “TB is a completely curable
disease. People in the government hospital, members of the
community, NGOs, doctors, nurses, BRAC should come for-
ward to educate people”. Health service providers think active
social awareness campaigns need to be created to prevent TB.
Local doctors, pharmacists, elected public representatives.
Imams of the mosques should work together to create aware-
ness among the community.
Training
Only one fourth of the health service providers had received
training on TB related issues while the remaining three fourth
did not receive such training. Among those who received train-
ing on TB more than half (54%) received refresher training.
Majority of the participants (83%) reported about further needs
of training on TB. BRAC organizes training on TB for the
NGOs like UTPS, CWFD etc. through whom the service is be-
ing provided. UTPS in Slum A area and CWFD through smil-
ing sun franchise in Slum B area provide trainings on TB to the
health service providers such as MBBS doctors, RMPs (rural
medical practitioners), diploma holde rs, per sons with allopathic
and homeopathic backgrounds, medical technologists, phar-
macy based drug sellers, and other related people in the com-
munity, i.e. religious leader, community leaders. NGO workers
who are involved in case detection and treatment of TB are also
given training. Basically service providers who are active in
these areas for a long duration of time are approached and se-
lected for training. Often newer service providers are left out.
Sometimes participants are selected through personal connec-
tion. One drug seller from Slum B quoted, “I send them patients,
they give me the opportunity to participate in the trainings”.
These trainings focus topics like causes of TB, signs and symp-
toms of TB, treatments, preventive measures, people vulnerable
for the disease etc. Besides, options for counseling for the posi-
tive patients, correct way of taking the drug, symptoms after
starting medication are also discussed. Most of the service pro-
viders found these trainings very useful. Through trainings they
acquire knowledge regarding not only the disease itself and its
treatment but also an idea about where to refer TB suspect pa-
tients. That’s why service providers who do not treat TB
thought that this kind of trainings can be very useful for them
also. So, if they can identify the disease and refer the patient
properly that will decrease delay in treatment significantly.
Beside this, they can play active role in the community in terms
of providing correct information. Unfortunately, most of these
service providers noted that they did not attend any refresher’s
training or any intermediate training. It’s very difficult for the
service providers to update and upgrade their knowledge if
there is no refresher’s and intermediate level training.
Recommendation from Health
Service Providers
Health service providers think that it is very important to
build awareness about TB among both health service providers
and patients. One of the ways is to organize campaigns by the
government including all service providers, imams of the
mosques, school teachers. They should be given training to
raise awareness of the community regarding prevention and
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E. HASIB ET AL.
treatment of TB. One drug seller quoted, “People must be made
aware. Those who do not know much about TB should be in-
formed. Those of us who are aware should make others aware”.
Sex workers and drug users must be aware of the problem.
Sewerage system of the slum areas needs to be improved. All
these need to be organized in a coordinated way. For example,
mostly people are at work during weekdays. So, any training
and awareness program should be run during weekends to en-
sure maximum participation from the community. Health
check-ups must be conducted in every 3 - 4 months. There
should be special emphasis on education in the slum area. In
fact, a special committee can be formed in each ward that
would take initiative to bring patients with symptoms of TB
under treatment. Activities and coverage of NGOs need to be
increased. Organizations like BRAC should take initiatives in
this regard. A coordinated effort is required to eliminate TB.
“Patients will get proper treatment if all organizations think the
same way”.
Conclusion
Controlling TB is a tough challenge for countries like Bang-
ladesh. However, BRAC’s approach to controlling TB through
DOTS in Bangladesh has achieved significant success by em-
ploying public private partnership. BRAC is the leading NGO
working with NTP for controlling TB, and it has also achieved
significant result. But in terms of urban areas, controlling TB
still remains a big challenge because of high population density,
unhealthy living environment, lack of necessary services and
also migratory characteristics of people. Interestingly, commu-
nity people are well aware of the infectious, contagious charac-
teristics of TB which is absolutely curable by proper medica-
tion. They have been gradually free from the misconception,
stigma and superstition related to TB. The problem they face is
living in unhygienic condition which is conducive for transmis-
sion of the disease. They cannot avert this situation. Regarding
the health seeking behavior, people of urban slum mostly come
in contact of health service providers in the early stage of the
disease. However, major problem in terms of TB lies with
completion of treatment. The long duration of DOTS program
was found to be the reason behind this. Also less reporting of
female patients still remains as a major concern. Diverse cate-
gories of health service providers were found in the study area
who provide treatment for patient with cough and fever for a
certain period of time and then they refer the patient to other
facilities if they fail to cure cough and fever. Generally drug
sellers, traditional healers, homeopath allopath (MBBS) practi-
tioners etc. are the primary point of contact of TB patients. As a
result of frequent trainings organized by NGOs and the gov-
ernment, even less qualified practitioners are aware about the
signs, symptoms, and symptomatic treatment. They know
where to refer for diagnosis and treatment. However, the exist-
ing referral system was found to be one of the causes that could
be a hindrance for achieving expected TB control success in
urban slums. This is because, in the study area, the referral
system mainly depends on existing informal relationship among
the health service providers and also between health service
providers and community people. This sometimes leads to re-
ferring patients to wrong service providers. NGOs and govern-
ment hospitals are providing correct treatment but usually pa-
tients go to drug sellers first when they have early symptoms.
So it all depends on the first point of contact where they refer
their patient for diagnosis and treatment. If they are not refer-
ring correctly then NGOs and government hospitals lose these
patients. So a systematic and formal referral system is a key to
achieve broader coverage of TB treatment. Formal network of
partnership can also help to scale up knowledge of first point of
contact through vigorous and periodic training. It has been evi-
dent from the study that health service providers who received
training from NGOs and government have more knowledge
than other service providers and can be instrumental in identi-
fying and referring patients. The mechanisms of TB programs
in urban areas of Bangladesh should seriously consider arrang-
ing regular training and monitoring health workforce, setting up
formal partnership among formal and informal health service
providers and generate information that policy-makers could
use to scale up the TB control program. Given the burden of
tuberculosis in the urban slum, TB control should continue to
remain a priority for coming years.
Acknowledgements
We would like to thank The Global Fund to fight AIDS, Tu-
berculosis and Malaria (GFATM) for providing financial sup-
port to James P Grant School of Public Health, BRAC Univer-
sity to conduct this research. We also thank Health Nutrition &
Population Programme of BRAC for providing technical sup-
port throughout the study.
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