title: DOT for patients with limited access to health care facilities in a hill district of eastern Nepal.
abstract: METHODS
  The hill district in Nepal, where access to health care facilities is difficult.
  
  
  OBJECTIVE
  To compare results before and after a decentralised directly observed treatment (DOT) intervention.
  
  
  METHODS
  Prospective study of patients registered in Dhankuta district, Nepal, 1996-1999. Patients received their intensive phase treatment under health worker supervision via one of three DOT options: 1) ambulatory from the peripheral government health facilities; 2) ambulatory from an international non-governmental organisation (INGO) TB clinic in district centre; or 3) resident in INGO TB hostel in district centre. Historical data from 1995-1996, with unsupervised short-course chemotherapy, were used for comparison.
  
  
  RESULTS
  Of 307 new cases, respectively 126 (41%), 86 (28%) and 95 (31%) took their intensive phase treatment via options 1, 2 and 3. Smear conversion (at 2 months) and cure rates in new smear-positive pulmonary tuberculosis cases were respectively 81.6% (vs. 58.8% historical, P = 0.001) and 84.9% (vs. 76.7% historical, P = 0.03). Overall costs to the INGO provider fell by 7%, mainly as a result of staffing reductions in the INGO services made possible by rationalisation with government services during the intervention.
  
  
  CONCLUSIONS
  By offering varied DOT delivery routes, including an in-patient option, satisfactory results are possible with DOT even in areas where access to health care facilities is difficult. Provision of in-patient care via an INGO TB hostel allowed a significant proportion of new cases (31%) to receive their intensive phase treatment who otherwise may have had difficulty accessing treatment, due either to the distance to the nearest health facility or to disease severity. Substitution of government hospital beds or local hotel beds for the INGO hostel beds may allow the model to be reproduced elsewhere in similar geographical conditions in Nepal, but further studies should be performed in a non-INGO supported district beforehand.
authors.affiliation: All Africa Leprosy, Tuberculosis and Rehabilitation Training Centre, Addis Ababa, Ethiopia. E.Waring@tesco.net
authors.forename: D F
authors.initials: DF
authors.lastname: Wares
authors.forename: M
authors.initials: M
authors.lastname: Akhtar
authors.forename: S
authors.initials: S
authors.lastname: Singh
mesh_terms: D000554:Ambulatory Care Facilities / Q000191:economics*; D000995:Antitubercular Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care / Q000191:economics*; D023801:Directly Observed Therapy / Q000191:economics*; D005240:Feasibility Studies; D006078:Government Programs / Q000191:economics*; D006801:Humans; D007390:International Agencies / Q000191:economics; D009390:Nepal; D010043:Outcome and Process Assessment, Health Care; D010865:Pilot Projects; D011446:Prospective Studies; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy* / Q000191:economics
chemical_list: D000995:Antitubercular Agents