1. Mittal Shah, Kent Ranson & Palak Joshi Reaching the poorest: SEWA’s experience with TB DOTS services

2. SEWA SEWA is a trade union of women workers in the informal economy Started in 1972 by Ela R. Bhatt Provides services in Ahmedabad City and 11 rural districts of Gujarat state Main goals: economic security and self- reliance Major activities: organizing, banking and micro-finance, insurance, capacity-building, health care 2003 membership in Gujarat: 4,69,306

5. SEWA Health Delivering services since 1980 Aims to serve the poorest Current services delivered: –Preventive: health education and training, ante-natal care, immunization, occupational and mental health activities –Curative: low-cost medicines, TB treatment, mobile RCH care, traditional medicines

6. SEWA’s TB DOTS services Since 1999 Partnership with WHO and government Targets North and East Zones of Ahmedabad City (population 375,000) 2003: 1,161 received treatment 5 stationary centers (each with 2-3 staff) and 11 grassroots DOTS providers Regular “area meetings” for demand creation Services free of charge

7. Research Methodology Phase I Qualitative Phase II Quantitative Phase III Qualitative

8. Research Methodology Objectives: Explore barriers to TB DOTS utilization Identify indicators of socio- economic status (SES) Activities: FGDs with TB DOTS users & non- users, including wealth-ranking In-depth interviews with service providers & managers Phase I Qualitative

9. Research Methodology Objectives: Assess SES among TB DOTS users versus (urban) non-users Activities: Exit-survey, >500 respondents Questions about households assets, utilities, dwelling and land ownership Interviewed all service-users over a 4 week period Compared to: Gujarat population, DHS 1998-99, N = 1,709 Ahmedabad population, LSHTM data, 2003, N = 749 Used wealth index, principal factors analysis Phase II Quantitative

10. Research Methodology Objectives: Validate findings of previous phases, with a focus on “Why did the service reach (or fail to reach) the poor?” Activities: In-depth interviews with service providers Phase III Qualitative

11. Findings: barriers to utilization Demand Fear of discrimination Some perceive quality to be low Personal events: e.g. weddings, funerals Migrant laborers can not attend regularly Alcohol addicted patients fail to comply Supply Side-effects result in drop-outs Special support required for dealing with alcohol addicted pts (or others with compliance problems, like migrants)

12. If the woman had TB, she would be sent away from her husband’s house, to her mother’s house! Her husband’s family would refuse to keep her in the house. So some women would not come, thinking about all this. Interview with SEWA Health grassroots worker Findings: barriers to utilization

13. If their in-law’s house is nearby then they are afraid that their engagement will be cancelled because of the disease… In one case, when we went to the patient’s house they did not like it at all. The next day the girl’s father called up to say angrily that no one should come to my house... her in-laws house is nearby. Interview with SEWA Health grassroots worker Findings: barriers to utilization

14. 663 TB DOTS users interviewed Of those interviewed (N = 663), 62% were men and 38% women Findings

15. Findings: Top 5 indicators of SES (DHS, urban Gujarat, 1998-99) Frequency RankVariable DHS (N = 1,709) TB DOTS (N = 663) 1If electricity lighting94.1%91.1% 2If biogas cooking fuel0.1%0.0% 3If gas cooking fuel57.0%33.8% 4If kaccha house5.3%13.6% 5If no toilet facility23.1%6.8%

16. Findings: Percentage distribution of urban SEWA Health service users by SES quintile (compared to DHS 1998-99)

17. Findings: Concentration curve, urban SEWA Health service (compared to DHS 1998-99) TB DOTS

18. RH Camps Women’s training TB DOTS Findings: Concentration curve, urban SEWA Health service (compared to DHS 1998-99)

19. Findings: Percentage distribution of urban SEWA Health service users by SES quintile (compared to LSHTM 2003)

20. Findings: Concentration curve, urban SEWA Health service (compared to LSHTM 2003) TB DOTS

21. Findings: Concentration curve, urban SEWA Health service (compared to LSHTM 2003) TB DOTS RH Camps Women’s training

22. SEWA Health’s TB DOTS services reach the poor: 69% of users from lowest 2 SES quintiles RH Mobile Camps slightly more successful in reaching the poor Substantial barriers to use by women Policy implications: summary of findings

23. Why are SEWA Health’s TB DOTS services successful in reaching the poor? Delivered to the “doorstep” in high-density urban areas Convenient timings Run by poor, local women and their own organization (cooperative) Combined with efforts to educate and mobilize the community Trust in SEWA Free of cost

24. How can SEWA Health’s TB DOTS services better reach the poor? Address the barriers faced by women –Educate households that TB is curable –Experience-sharing by women who have been cured Develop special supports for alcohol addicted patients –Involvement of family and community in treatment Improve education about, and treatment of, side- effects More trained peripheral DOTS workers to provide to those who live far from centres