Tuberculosis treatment in Nepal: a rapid assessment of government centers using different types of patient supervision

SETTING: Urban and periurban government tuberculosis (TB) treatment clinics in Nepal. OBJECTIVE: To assess TB treatment supervision strategics and outcomes. DESIGN: Three types of treatment centers were selected according to intensi ty of treatment supervision: Group A-all patients supervised by directly ob served therapy (DOT) at the treatment center during the intensive phase; Gr oup B-flexible DOT where patient-nominated treatment supervisors include co mmunity or family members; Group C-drugs dispensed monthly and no supervise d treatment. The cohort studied comprised all new patients starting treatme nt during a S-month period in 1996 (n = 759). RESULTS: At group A treatment centers, 100% of patients had daily DOT super vised by treatment center staff during the intensive phase. At group B site s, 75% of nominated supervisors were family or community members and 13 % o f patients had no super-visor. At group C sites 93% of patients were unsupe rvised. Bacteriologically confirmed cure rates for smear-positive patients were 91% (9S%CI 80.3-97.2) for A sites, 57% (95%CI 48.8-64.0) for B, and 34 % (95%CI 25.1-40.4) for C. Treatment centers with the best results had good access to laboratory facilities, uninterrupted drug supply, longer clinic hours, standardized TB case management, and support from a non-governmental organization. CONCLUSION: At government facilities in Nepal, only group A treatment cente rs achieved World Health Organization global targets for cure. Group B trea tment centers showed better outcomes than unsupervised therapy but did not achieve cure targets. Rapid low-cost assessments to collect data that are n ot routinely reported can improve the evaluation of program aspects such as supervision strategies.