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The Big Cough – Malawi
The widespread nature of tuberculosis (TB) in Malawi has led to the country being dubbed ‘The Big Cough’. With the number of TB cases more than doubling in the past 15 years, the time is ripe for change. Malawi’s National Tuberculosis Control Programme has approached this through a partnership with the Liverpool School of Tropical Medicine. The resulting initiative has produced new ways of encouraging TB patients to seek treatment – for example, storekeepers have been given the power to diagnose their customers with TB, and so can refer patients directly to hospital.
Malawi’s Health Problems
Malawi is a small, landlocked country in central Africa with a population of about 10 million people. It is one of the poorest countries in the world with its annual per capita income of about US$170. Health problems in Malawi are pervasive and still on the increase. Life expectancy at birth dropped from 43 years in 1996 to 39 years in 2000. The country has been hard hit by the dual epidemics of HIV and TB. TB is one of the country’s leading causes of death, with an incidence of 24 in every 10,000. The incidence of TB is soaring because of its link to the HIV/AIDS epidemic in most sub-Saharan countries. In Malawi, 77 per cent of TB patients are HIV positive.
Barriers to controlling TB include difficulties in case-finding, the social and economic costs of TB and its treatment, as well as inadequate access to health care. A major problem leading to Malawi’s poor health indicators is a lack of qualified and adequately paid medical staff, in terms of doctors, nurses and related personnel. This problem is particularly acute in rural areas and has been deepened by the combined HIV/AIDS and TB epidemic. This results in high population to physician ratios, estimated at 45,737 to 1.
What is TB?
“When I look at TB, I see a scandal. We have had the means to diagnose TB for over 100 years, and drugs to treat TB for 50 years. Yet TB remains a leading infectious killer of adults. 95% of the annual global toll of two million TB deaths and eight million new TB cases occur in developing countries.”
Clare Short MP, Ex-Secretary of State for International Development |
Tuberculosis is an infection that usually affects the lungs (pulmonary TB), but TB germs can spread to other organs in the body (extrapulmonary TB). When people are exposed to TB germs and become infected, they have TB infection. Sometimes this infection develops into active TB, but not everyone infected with TB germs develops active TB. According to World Health Organization (WHO) estimates, each year around eight million people develop TB, but treatment currently reaches only about a quarter of these people. Approximately 1.8 million people die each year from TB.
A problem with TB is that many people in the developing world do not seek treatment. This may be for a variety of reasons:
· It would mean taking time off work or away from family commitments.
· Those with HIV and the elderly, among others, may be too weak to visit a health centre.
· People may not be able to pay for the cost of transport to the health centre, or diagnosis, or drugs.
· People may not view health services as ‘user-friendly’ and may choose instead to visit a private or traditional health practitioner.
· Women especially may be worried about the stigma and discrimination surrounding TB and HIV/AIDS.
People infected with HIV are more likely to develop active TB after they have been exposed to TB germs because they have weakened immune systems, so the TB germs multiply quickly. People who are infected with both TB and HIV are 25–30 times more likely to develop active TB than people who are only infected with TB. Deaths from TB are expected to double to four million people a year by 2010 as HIV makes people more vulnerable; according to WHO estimates one-third of TB deaths are people with HIV.
TB is spread through coughing: a person who has TB coughs TB germs into the air and other people can breathe them into their lungs. Most people with TB who are on appropriate treatment are not infectious and therefore can work, socialise and live with people without infecting them.
Symptoms of TB
- A strong cough for more than three weeks.
- Loss of appetite or weight.
- Night sweats.
- Tiredness.
- Chest pains.
- Coughing blood.
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The Malawi National Tuberculosis Control Programme
Since 1985, Malawi has operated a model TB control programme outlined by the International Union Against Tuberculosis and Lung Diseases (IUATLD). The Malawi National Tuberculosis Control Programme has a similar administrative structure to other government departments, and is supported by IUATLD and foreign donors. Management occurs at a national level, with district TB officer support. The UK’s Department for International Development (DFID) has supported the programme for 15 years, and the Tuberculosis Control Programme has an effective and internationally recognised system known as ‘directly-observed treatment, short-course’ (DOTS). The cure rate in 1998 was 66 per cent and the case fatality rate was 22 per cent. The number of fatalities has escalated in the past 15 years.
What is DOTS?
In Malawi, the WHO’s directly-observed treatment, short-course strategy for TB consists of:
· Diagnosis in the general health service, using sputum microscopy.
· Standardised short-course drug treatment, supervised primarily at health facilities but increasingly also in the home.
· Regular uninterrupted drug supplies.
· Accurate record-keeping, supervision and programme evaluation.
· Government commitment to TB control. |
The decentralisation of TB services occurred in 1998 in Malawi’s capital, Lilongwe, as an operational research project when five urban health centres were formed. In 1999 the Tuberculosis Control Programme embarked on a novel partnership with the Liverpool school of Tropical Medicine and the University of Malawi. This partnership started as the TB Equity Project and is now called the Equi-TB Knowledge Programme. The initiative is funded by DFID, and aims to promote equity in access to TB care by:
· Exploring the barriers that TB patients, their families and communities face in accessing TB diagnosis and treatment.
· Responding to the barriers with practical TB-focused initiatives to improve access, particularly for the poorest and most vulnerable.
The Tuberculosis Control Programme has responded positively to the problems presented by TB patients, their families and communities in a number of ways. This includes initiating a guardian-based option for TB treatment, which is very popular with patients. Patients have the option to be observed taking their TB drugs at home at a time convenient to them, allowing them to continue with their day-to-day activities.
A second response has been targeting initiatives at the poorest communities. One of these initiatives is called the Extending Services to Communities Project.
Project Objectives
- To develop a package aimed at improving the advisory skills of storekeepers and the health promotion skills of community leaders.
- To improve the capacity of the City Assembly and urban Community Health Committees to work with communities to improve their health and health services.
- To improve the advisory skills of storekeepers and community leaders in the treatment and referral of TB patients.
- To improve the skills of community leaders in health promotion of TB and awareness raising of the new advisory role of storekeepers.
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Extending Services to Communities
The Extending Services to Communities Project secured a grant from the Norwegian Heart and Lung Patient Organisation to link with grocery stores, where people first buy their medicines for coughs, to encourage early referral for TB diagnosis. Private storekeepers are a community resource that has an established role in the early treatment of diseases. Before going to a diagnostic centre, TB patients have been found to seek treatment from private health providers including traditional healers, private clinicians, pharmacists and storekeepers. These habits in seeking treatment may contribute to delays in starting appropriate treatment. A household survey in Malawi showed that in Lilongwe 70 per cent of childhood fevers were first treated at home, mainly inappropriately with shop-bought paracetemol or aspirin. Only 4 per cent of childhood fevers were treated within 24 hours with the appropriate treatment and only a small proportion of those used the correct dose.
Storekeepers are widespread in both urban and rural areas, usually providing a reliable and accessible source of drugs in the absence of public health services at the community level. The self-sustainable nature of these storekeepers makes them valuable for involvement in public health initiatives for resource-poor communities. The project is targeted at the poorest communities within urban Lilongwe (Ngwenya and Kuama), Chinsapo, and Senti. The package consists of: training manuals for health promotion; training manuals for storekeepers; flipcharts to be used for health promotion; and drug charts.
Both TB patients and storekeepers are finding the resource hugely beneficial.
“One striking thing which I’ve noticed is that the storekeeper has given me a referral letter which I perceive to be very important because if you take a referral letter to the hospital the health workers can help you quickly because they know that this person needs help and the community has identified you as a person who should be helped by the health centre.”
TB patient
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“Referring the customers to the hospital is not a loss to my business because the more I send customer the more I’ll have friends. If they go to the hospital and get appropriate help then they will always refer to me as the source of their health”.
Jabesi Chinyama, Storekeeper. |
Storekeeper Doctors
By enabling storekeepers to diagnose their customers with TB, a major barrier to treatment and prevention has been approached. One of the main problems facing the health conditions in Malawi is the way people seek informal help for their ailments. Storekeepers are highly regarded in communities in Malawi, and so being referred by a storekeeper encourages patients to seek professional help from health centres. This small step may play a vital role in solving the ‘big cough’.
Acknowledgements
Practical Action would like to thank the Liverpool School of Tropical Medicine for providing information and helping in this case study.
The case study draws on articles written by the Liverpool School of Tropical Medicine.
Further Information
Reference Material
Kelly, P. M. (2001). “Local problems, local solutions: tuberculosis control at the district level in Malawi”. Bulletin of the World Health Organisation. 79 (2): 111-117.
World Bank (2002). Malawi Poverty Reduction Strategy Paper.
Participating Organisations
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool L3 5QA
UK
Phone: +44 (0)151 708 9393
Fax: +44 (0)151 705 3370
E-mail: imr@liverpool.ac.uk
Website: http://www.liv.ac.uk/lstm/index.htm
Malawi National Tuberculosis Control Programme
TB Programme Manager/Officer-In-Charge
Ministry Of Health & Population
Community Health Sciences Unit
Private Bag 65
Lilongwe
Malawi
Tel: +265 (0)1 757475
Fax: +265 01 751247
E-mail: tbcontrol@malawi.net
Supporting Organisations
Department for International Development (DFID)
1 Palace Street,
London
SW1E 5HE
Tel: +44 (0)20 7023 0000
Fax: +44 (0)20 7023 0019
E-mail: enquiry@dfid.gov.uk
Website: http://www.dfid.gov.uk/
US AID
Information Centre
Ronald Reagan Building
Washington, D.C. 20523-1000
USA
Tel: +1 202-712-4320
Fax: +1 202-216-3524
Website: http://www.usaid.gov/
Resources
Health Link Worldwide
Cityside, 40 Adler Street, London E1 1EE, UK
Tel: +44 20 7539 1570
Fax: +44 20 7539 1580
E-mail: info@healthlink.org.uk
Website: www.healthlink.org.uk
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Bourton On Dunsmore
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UK
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Fax: +44 - 01926 634401
Website: www.practicalaction.org/
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