28 Do private doctors.pmd

As private medical practitioners play a major role of in providing care to pulmonary tuberculosis (TB) patients, a survey was made of knowledge and practice in 2 cities in Pakistan. Only 1 of the 245 physicians was aware that cough > 3 weeks alone is the main symptom suggesting pulmonary TB. The majority diagnosed (80%) and treated (83%) cases themselves without referral. Less than 1% relied on sputum microscopy alone for diagnosis. None of the practitioners were following National TB Control guidelines for prescribing drugs and none ensured compliance with anti-TB treatment under supervision of a doctor/health worker. Only 3% kept records of pulmonary TB patients. None of the physicians assessed the effectiveness of treatment with sputum microscopy alone; the majority (76%) used only clinical assessment. 1National Tuberculosis Control Programme, Rawalpindi, Pakistan. Les médecins privés suivent-ils les directives nationales pour le diagnostic et le traitement de la tuberculose pulmonaire au Pakistan ? RESUME Etant donné que les médecins privés jouent un rôle important dans la prestation de soins aux patients atteints de tuberculose pulmonaire, une étude a été réalisée sur les connaissances et les pratiques dans 2 villes du Pakistan. Un seul médecin sur les 245 savait qu’une toux seule de plus de 3 semaines était le principal symptôme évocateur d’une tuberculose pulmonaire. La majorité d’entre eux diagnostiquaient (80 %) et traitaient (83 %) les cas eux-mêmes sans les orienter vers un spécialiste. Moins de 1 % s’appuyaient sur la microscopie des expectorations seule pour le diagnostic. Aucun des médecins ne suivait les directives du programme national de lutte antituberculeuse pour la prescription des médicaments et aucun n’assurait l’observance du traitement antituberculeux sous surveillance d’un médecin/agent de santé. Seulement 3 % des médecins tenaient des dossiers sur les patients atteints de tuberculose pulmonaire. Aucun des médecins n’évaluait l’efficacité du traitement par l’examen microscopique des expectorations ; la majorité (76 %) utilisait uniquement l’évaluation clinique. 28 Do private doctors.pmd 2/21/2005, 1:38 AM 776 Eastern Mediterranean Health Journal, Vol. 9, No. 4, 2003 777 2003 ,4 ef®aA ,©mBNaA foV¿aA ,“ŒùB®aA “ZvaA “¿•ƒø ,°mÃNùA ∂jra “ŒZvaA “oVùA Introduction Tuberculosis (TB) is the largest single infectious cause of death among young people and adults in the world, accounting for nearly 2 million deaths a year; about a third of the world’s population harbours the infection [1]. This large pool of infected people means that TB will continue to be a major problem in the foreseeable future [2]. While they belong to all socioeconomic strata, the great majority of TB patients are poor [3]. Due to these and many other relevant factors, the TB epidemic was declared a global emergency by the World Health Organization (WHO) in 1993 [4]. TB remains one of the major public health problems in Pakistan. Moreover, WHO has identified Pakistan as among the countries with a high burden of disease [5]. According to the Pakistan national TB survey in 1987–88 [6] the prevalence of sputum-positive or open cases of pulmonary TB was estimated to be 0.17 per 1000 population. These open cases form a reservoir of infection in the community and are the source of person-to-person transmission. In Pakistan where only 36% of the population is literate and 28% is living below the absolute poverty line [7], the private sector makes a major contribution to providing health care for all kinds of health problems including the management of TB cases [8]. Private medical practitioners in Pakistan, as in other developing countries, comprise a wide range of health care providers, ranging from unqualified and unskilled practitioners to highly qualified medical postgraduates. However, a large number are in the former category, who are readily available and accessible especially in the rural settings where 70% of Pakistan’s population lives. The absence of any effective regulatory mechanism further worsens the situation. In India it has also been noted that the private health sector in developing countries tends to be a relatively amorphous, unorganized and dynamic entity comprising various provider types of different sizes and characteristics [9]. There is increasing interest in many countries about the role of the private health sector in TB care [7]. In a study of health-seeking behaviour in Pakistan [10], it was found that 90% of TB patients had initially contacted a private practitioner before visiting a TB centre. Similarly, another study in a different setting also established that 80% of hospitalized TB patients had first consulted private practitioners [11]. Moreover, a study in India observed that 86% of TB patients had first consulted a private practitioner [12]. Yet TB patients attending the private sector may not be receiving the correct treatment according to the National Tuberculosis Control Programme guidelines. The present study was carried out to determine the knowledge and practices of private general medical practitioners towards diagnosis, treatment and follow-up of pulmonary TB patients in 2 cities of Pakistan. In addition, we intended to collect baseline information to plan future interventions to involve the private sector in the National TB Programme.