Mittal Shah, Kent Ranson & Palak Joshi

Reaching the poorest: SEWA’s experience with TB DOTS

services

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

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

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

Research Methodology

Phase I Qualitative

Phase II Quantitative

Phase III Qualitative

Research MethodologyObjectives:

• 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

Research MethodologyObjectives:• 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

Research MethodologyObjectives:• 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

Findings: barriers to utilizationDemand• 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 complySupply• Side-effects result in drop-outs• Special support required for dealing with

alcohol addicted pts (or others with compliance problems, like migrants)

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

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

• 663 TB DOTS users interviewed

• Of those interviewed (N = 663), 62% were men and 38% women

Findings

Findings: Top 5 indicators of SES (DHS, urban Gujarat, 1998-99)

Frequency

Rank VariableDHS

(N = 1,709)TB DOTS (N = 663)

1 If electricity lighting 94.1% 91.1%

2 If biogas cooking fuel 0.1% 0.0%

3 If gas cooking fuel 57.0% 33.8%

4 If kaccha house 5.3% 13.6%

5 If no toilet facility 23.1% 6.8%

Findings: Percentage distribution of urban SEWA Health service users by SES quintile

(compared to DHS 1998-99)

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

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on TB DOTS

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on

RH Camps

Women’s training

TB DOTS

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

Findings: Percentage distribution of urban SEWA Health service users by SES quintile

(compared to LSHTM 2003)

Findings: Concentration curve, urban SEWA Health service (compared to LSHTM 2003)

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on

TB DOTS

Findings: Concentration curve, urban SEWA Health service (compared to LSHTM 2003)

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on

TB DOTS

RH Camps

Women’s training

• 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

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

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