Factors influencing dots default in Kabul : need a responsive health care system-more than ever!

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


Background Afghanistan is one of the 22 Tuberculosis high burden countries of the world. Directly Observed Treatment Short course (DOTS) is adopted since 1997 and delivered in integration with Basic Package of Health Services (BPHS). Despite the country is close to achieving the global targets of TB case detection of 70% and has exceeded the treatment success rate of 85% at national level but still challenges of addressing quality DOTS and Multi Drug Resistance (MDR) TB are ahead. Kabul where more than 4 million populations is living, TB treatment success rate is 57% comparing to 85% at national level. Defaulter rate is 5% in Kabul compare to 2% at national level. Moreover high transferred out (33%) in Kabul is assumed to be defaulted. This situation is quite alarming and could be considered a potential risk for MDR-TB, while there is lack of evidence to guide policy in this regard. Therefore this study was aimed to explore the potential factors influencing DOTS default in Kabul city. Objectives To explore the potential factors in fluencing DOTS default by investigating perceptions of key stakeholders i.e. Treatment after Defaulters (TADs) registered in 2009-10, DOTS providers, and TB program managers and experts in Kabul city To identify characteristics of d efaulters from TB registers of DOTS centers in Kabul city for last three years i.e. 2006-08 Methodology Concurrent embedded mixed method strategy was used. Quantitative part involved secondary data collection of defaulters from TB registers for the last three years (2006-2008). Qualitative part included Focus Group Discussions, semi structured and in depth interviews with DOTS providers, Treatment after Defaulters, and. TB experts and managers respectively. Descriptive analysis was carried out for secondary data of defaulters whereas selective coding was used for thematic analysis of qualitative data. Results We found in total 253 pulmonary TB patients defaulted from DOTS centers of Kabul city during 2006-2008. Descriptive analysis shows that more male (8.3%) compared to female (6.3%), and more sputum smear negative (14.11%) compared to sputum smear positive (4.16 %) and retreatment cases (3.4%) defaulted during 2006- 2008. Most of defaulters were in 21-40 years of age group, mean distance of place of residence from DOTS centers was 7.54 Km and mean duration of treatment received was 2.6 months for these defaulters. Our qualitative findings suggest low knowledge of TB patients about TB treatment, lack of proper counseling, and attitude of health personnel, financial constrains and poverty as key factors potentially influencing DOTS default in Kabul city. Other includes transportation issue, easily accessible private health sector, social stigma, and non functioning of default tracing system, lack of referral TB hospital, migration and patient flow from other areas of the country. Conclusion and Recommendations No previous study has been conducted so for in regard in Afghanistan. Literature search portrays that our findings are in accordance with evidence from region and other TB high burden settings. Our findings conclude that TB DOTS default is due to overall health care system inefficiency neither uninformed TB patient nor demotivated health personnel alone should be blamed. Our conclusion calls upon National TB control program to devote attention to promote caring attitude through skilled and motivated health personnel in order to provide quality information regarding importance of adherence to treatment course at initial counseling and especially when patient shifts from initial phase to continuation. Activation of defaulter's tracing mechanism on immediate basis is the need of hour. Our findings also suggest some flexibility in DOTS implementation to respond to issue of financial constrains and poverty. We strongly recommend moving towards Community based DOTS as empirical strategy for improvement of TB treatment outcome and many other issues related to TB.

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