Treatment referral system for tuberculosis patients in Dhaka, Bangladesh.

Bangladesh is one of the 22 high tuberculosis (TB) burden countries identified by the World Health Organization (WHO), with a prevalence of 402 per 100 000 population and an incidence of 224/100 000 per year.1 Governmental, non-governmental and private sector providers are highly committed to working together to achieve TB control.2 One of the current priorities of the Bangladesh National TB Programme (NTP) is to develop an urban strategy that can effectively engage diverse health care providers in providing accessible care for the poor.3 The population density of Bangladesh's capital, Dhaka, is about 19 380 per km2 (50 000/square mile),4 and the total population is 14.5 million.5 There is a basic health care delivery system in Dhaka City, with designated areas where non-governmental organisation (NGO) clinics provide primary health care. The NTP adopted the DOTS strategy for the country in 1993, and expanded DOTS services to Dhaka Metropolitan Area in 2002 through mixed public-private activities. The NTP has set up a referral system across providers designed to enable early diagnosis and convenient treatment. A total of 17 DOTS corners have been established in different tertiary level hospitals in both the public and private sectors where a large number of TB patients are diagnosed. NGOs also manage 115 DOTS centres, providing free treatment for TB across the city.6 Orientation programmes are conducted to inform different professionals from these institutes about DOTS and the national guidelines. Individuals with TB symptoms and diagnosed patients are referred from in-patient and out-patient departments to the respective DOTS corner.7 Following diagnosis, patients who live near the DOTS corner are registered there, while others are referred to the centre nearest to their homes for registration.8 Seriously ill patients are admitted to hospital to receive initial treatment from attending nurses and are later referred to the nearest local centre to complete treatment.9 Completion of anti-tuberculosis treatment is challenging due to the long duration of treatment.10 Patient convenience and satisfaction with services are important factors in treatment success. Effective counselling increases treatment completion and reduces loss to follow-up.11 Because the diagnosis and treatment sites are usually different, treatment initiation is a key challenge in urban TB control. In the current system, when a TB case is confirmed, a referral form is completed. A copy of this form is given to the patient, who is sent to the recommended treatment facility, and the original is retained by the referring facility. The receiving facility completes the bottom part of the form and returns it to the referral institution as soon as the patient reports for treatment.12 If a patient fails to report for treatment, there is no comprehensive mechanism in place to trace them.