INT J TUBERC LUNG DIS 5(10):920925

2001 IUATLD

High tuberculosis notification and treatment success rates

through community participation in central Sulawesi,
Republic of Indonesia
M. Becx-Bleumink,* H. Wibowo, W. Apriani, H. Vrakking*
* KNCV, The Hague, The Netherlands; Communicable Disease Control (CDC), Palu, Central Sulawesi, Indonesia
SUMMARY
S E T T I N G : Central Sulawesi Province, Republic of
Indonesia.
O B J E C T I V E : To increase tuberculosis case notification
and maintain high treatment success rates through community participation in a tuberculosis field programme.
D E S I G N : Comparison of tuberculosis case notification
and treatment results in a community based tuberculosis
programme (CBTP), before and after introduction of the
programme and between areas where the programme
was and was not introduced.
R E S U L T S : During 1998, the CBTP was introduced in
two of the four rural districts of the Central Sulawesi
province, covering 224 (29%) of the 772 villages and
362 700 (33%) of the 1 109 100 population in these districts. In the CBTP villages the notification rate of new
smear-positive patients per 100 000 population increased from 51 in 1996 and 48 in 1997 to 166 in 1998.
In the 548 non-CBTP villages the rates were 62, 60 and

70, respectively. The sputum conversion rate at the end

of the first 2 months of the treatment was over 85% in
both the CBTP and the non-CBTP villages. In the CBTP
villages the treatment success rate (cure and treatment
completion) was 90.4%, 89.5% and 93.7% in 1996,
1997, and 1998. For the non-CBTP villages these rates
were respectively 85.4%, 86.8% and 85.9%. In 1998
the sputum conversion and treatment success rates were
significantly higher in the CBTP villages than in the nonCBTP villages.
C O N C L U S I O N : Through community participation, the
notification of new smear-smear positive patients increased substantially, while sputum conversion and
treatment success rates remained high.
K E Y W O R D S : tuberculosis control; community participation; community based tuberculosis control; case notification; treatment results

INDONESIA is one of the countries where tuberculosis is a major health problem. In 1999 the World
Health Organization (WHO) estimated that 590 000
persons developed tuberculosis each year in Indonesia, which is equivalent to 282 per 100 000 population. The annual incidence of new smear-positive patients was estimated at 265 000, which is equivalent
to 127/100 000.1
During 1993, a pilot project whereby weekly directly observed treatment was given by health centre
staff during the initial 2 months and fortnightly during the remaining 4 months was introduced in eight
health centres of the Central Sulawesi province. It
was implemented in all 103 health centres of the
province during 1995.
Since the start of the project the sputum conversion rate among new smear-positive patients has been
80% and over, and the treatment success rate (cure
with confirmed bacteriology and treatment comple-

tion) above 85%. The notification rate of new smearpositive patients increased from 31/100 000 during
1995 to 56 during 1997, which can be explained by
the involvement of hospitals and private practitioners
and increasing awareness among health centre staff
about the selection of suspect tuberculosis cases.
The annual incidence of smear-positive pulmonary
cases in Central Sulawesi is not known. For the calculation of notified patients as a percentage of estimated
patients, the average national annual incidence of
smear-positive tuberculosis cases of 127/100 000 population was used as denominator. Based on this it was
concluded that fewer than 50% of smear-positive patients are detected. From discussions with supervisors
and health centre staff it was concluded that the services were not reaching the people in remote areas
who depended mainly on sub-centres that did not
provide tuberculosis control services. Furthermore,
cultural beliefs, shame at being known to be tubercu-

Correspondence to: Dr Marijke Becx-Bleumink, Senior Consultant Tuberculosis, Royal Netherlands Tuberculosis Association, PO Box 146, 2501 CC The Hague, The Netherlands. Tel: (31) 70 390 6112. Fax: (31) 70 390 6175. e-mail:
becxm@kncvtbc.nl
Article submitted 28 February 2001. Final version accepted 23 July 2001.

TB control through community participation

lous, lack of money to pay for transport to attend a

health centre, and lack of awareness about free diagnosis and treatment may prevent patients from coming forward for diagnosis and treatment.
In order to increase notification of smear-positive
patients and maintain high treatment success rates a
community based tuberculosis programme (CBTP)
was introduced in 1998. This paper describes the
steps that have been taken to mobilise communities
on tuberculosis and train sub-centre health workers
in delivery, observation and recording of treatment.
Notification data on new smear-positive patients and
treatment results before and after introduction of the
CBTP are presented and discussed. The data of the
CBTP villages are compared with those of the remaining villages (referred to as non-CBTP villages).

SETTING
The Central Sulawesi province consists of five districts, four rural districts and a municipality, with a
total population of just over 2 million at the end of
1998.
Details about detection, diagnosis and treatment
of tuberculosis patients before the CBTP was introduced have been published previously.2 In short, casedetection is done through sputum smear examination
of patients presenting at a health centre with suspect
tuberculosis, diagnosis is by sputum smear-microscopy carried out in selected health centres, and treatment is given in all health centres upon prescription
by a medical officer or trained nurse. All patients with
a diagnosis of new smear-positive tuberculosis are
treated daily with four drugs (rifampicin, isoniazid,
pyrazinamide and ethambutol) for the first 2 months,
followed by rifampicin and isoniazid three times
weekly for 4 months. At the onset of treatment a box
of drugs is reserved for each patient. The patient is requested to identify a household member or other
community member for observation of treatment at
home, six times per week during the first 2 months and
five times per fortnight during the last 4 months. Drugs
are provided in blister packs containing the drugs for
one day.
Samples of smears for all smear-positive patients
and for 10% of smear-negative suspects are routinely
re-examined by provincial laboratory technicians,
with the readers being blinded to the result of the peripheral laboratory. Over the years concordance of
results between the peripheral laboratories and the
reference laboratory has been over 95%.

METHODS
During 1998 the CBTP was introduced in 224 (29%)
of the 772 villages of two rural districts, covering
362 700 (33%) of the 1 109 100 population of these
districts.

921

To select participating communities, and to mobilise and train the community and sub-centre health
workers, the following steps were taken:
Health centres were selected by provincial and district staff. Selection criteria were higher-than-average
treatment resultssputum conversion and treatment
outcomeduring the previous 2 years. The provincial and district tuberculosis supervisors and health
centre staff met to discuss the purpose of the CBTP,
after which villages were selected by health centre
staff and approved by the district supervisor.
Health education was provided and information
disseminated to the leaders of the selected villagers,
including the village heads, religious leaders and
members of special groups such as Womens Associations. Health education was also provided to the
community, in co-operation with the leaders, in order
to: 1) convince the people that tuberculosis is a village
health problem and that infectious tuberculosis patients can infect their family and community members;
2) explain about the disease, its symptoms, and diagnosis; 3) explain that the disease can be cured, that diagnosis and treatment are available free of charge, and
that treatment can be most successful through community participation, and 4) encourage patients with
chronic cough to go to the village hall or health centre
to have their sputum taken for examination.
Sub-centre health workers and village midwives
were trained in selection of tuberculosis suspects, delivery and observation of treatment, including selection and guidance of household members, and record
keeping.
After diagnosis at a health centre or hospital the
patients are registered at the sub-centre in their village. Sub-centres are under the responsibility of a
health centre and they serve a number of villages
whose populations vary from a few hundred to several thousand. During the intensive phase of treatment patients attend the sub-centre once weekly
when the treatment for that day is given under direct
observation. During the continuation phase patients
attend the sub-centre every fortnight. The drugs for
the remaining days are given to the patient in blister
packs. A household member is requested to observe
the treatment at home; the name of the treatment observer is written on the Patient Record Card.
Diagnosed patients are known in the community,
and the members of the community are expected to
support them. Patients who do not want to be known
as tuberculous for whatever reason have the choice of
visiting the health centre for weekly and fortnightly
observation of treatment and collection of drugs.
They are also requested to select a household member
for observation of treatment at home.
In order to guide and supervise the implementation
of the CBTP, health centre staff visit the villages regularly, initially monthly and thereafter every 2 months.
The district tuberculosis supervisors supervise the

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The International Journal of Tuberculosis and Lung Disease

Table 1 Numbers of new smear-positive patients notified

and case-notification rates per 100 000 population in CBTP
and non-CBTP villages in two rural districts of Central Sulawesi
CBTP village
Year

Patients
n

1996
1997
1998

177
171
603

Non-CBT village

CNR

Patients
n

51
48
166

444
439
519

CNR

Total
Patients
n

CNR

62
60
70

621
610
1.122

58
56
101

CBTP  Community Based Tuberculosis Programme; CNR  case notification

rate of new smear-positive patients per 100 000 population.

participating health centres with the same frequency.

The health centres in the non-CBTP areas are visited
quarterly according to routine policy. Funds for visits
by health centre staff and supervision by tuberculosis
supervisors are obtained from external sources.
The Tuberculosis Treatment Cards, District Tuberculosis Register, recording and reporting forms are
those recommended by the International Union
Against Tuberculosis and Lung Disease (IUATLD).3
Notification rates are expressed as numbers of new
smear-positive patients notified during a year per
100 000 population. Sputum conversion data and
treatment results are routinely reported by district for
quarterly cohorts of patients. For the purpose of this
study, data on notification, conversion and treatment
results were separate for the CBTP villages and the
non-CBTP villages, retrospectively for 1996 and
1997 and prospectively for 1998.
Conversion and treatment outcome data were entered into Epi-Info version 6.0 software (CDC, At-

lanta, GA). Treatment outcomes of patients in the

CBTP villages were compared with those of patients
in the non-CBTP villages, using the 2 test with differences at the 5% level being regarded as significant.

RESULTS
For 1996 and 1997 the notification rates per 100 000
population were 51 and 48, respectively, in the CBTP
villages, and 62 and 60 in the non-CBTP villages (Table 1). During 1998 the rate more than tripled to 166
in the CBTP villages, and increased slightly to 70 in
the non-CBTP villages.
Sputum conversion results at the end of the first 2
months of the treatment are presented in Table 2. For
1996 and 1997 the conversion rate is higher in the
CBTP villages, but the difference is not statistically significant. For 1998 the conversion rate is significantly
higher for patients treated in the CBTP villages.
The percentage of patients with positive smears at
the end of the first 2 months of treatment decreased
significantly over the years in both the CBTP and the
non-CBTP villages.
Treatment results are given in Table 3. During the
three years covered by the study, the treatment success rate (cure plus treatment completion) is above
85% in both the CBTP and the non-CBTP villages.
The rate is higher in the CBTP than in the non-CBTP
villages. For 1996 and 1997 the difference is not statistically significant, but for 1998 the treatment success rate is significantly higher in the CBTP villages.
The decline in failure rate in both the CBTP and the
non-CBTP villages is statistically significant.

Table 2 Sputum conversion at the end of the first 2 months of treatment in CBTP
and non-CBTP villages in two rural districts of Central Sulawesi

1996
Result
Smear-negative
Smear-positive
Other*
1997
Result
Smear-negative
Smear-positive
Other*
1998
Result
Smear-negative
Smear-positive
Other*
Comparison over the years
Smear-negatives, CBTP
Smear-negatives, non-CBTP
Smear-positives, CBTP
Smear-positives, non-CBTP

CBTP
n (%)

non-CBTP
n (%)

n  177

n  444

160 (90.4)
14 (7.9)
3 (1.7)
n  171

2

387 (87.2)
33 (7.4)
24 (5.4)
n  439

0.97

0.32

154 (90.1)
9 (5.3)
8 (4.6)
n  603

379 (86.3)
24 (5.5)
36 (8.2)
n  519

1.23

0.27

563 (93.4)
10 (1.7)
30 (4.9)

462 (89.0)
16 (3.1)
41 (7.9)

6.14

0.01

3.04
1.69
17.96
9.26

0.22
0.43
0.01
0.01

* Patients still on treatment at the end of the first 2 months, but who had no smear examination, died or were transferred out.
CBTP  Community Based Tuberculosis Programme.

TB control through community participation

923

Table 3 Treatment results in CBTP and non-CBTP villages in two rural districts
of Central Sulawesi

1996
Outcome category
Cured
Treatment completed
Treatment failure
Died
Defaulted
Transferred out
Total treatment success
1997
Outcome category
Cured
Treatment completed
Treatment failure
Died
Defaulted
Transferred out
Total treatment success
1998
Outcome category
Cured
Treatment completed
Treatment failure
Died
Defaulted
Transferred out
Total treatment success

CBTP
n (%)

Non-CBTP
n (%)

n  177

n  444

141 (79.7)
19 (10.7)
3 (1.7)
4 (2.3)
8 (4.5)
2 (1.1)
160 (90.4)

339 (76.4)
40 (9.0)
11 (2.5)
29 (6.5)
18 (4.1)
7 (1.6)
379 (85.4)

n  171

n  439

136 (79.5)
17 (9.9)
2 (1.2)
8 (4.7)
8 (4.7)
153 (89.5)

349 (79.5)
32 (7.3)
5 (1.1)
25 (5.7)
27 (6.2)
1 (0.2)
381 (86.8)

n  603

n  519

533 (88.4)
32 (5.3)
1 (0.2)
23 (3.8)
10 (1.7)
4 (0.7)
565 (93.7)

417 (80.3)
29 (5.6)
3 (0.6)
17 (3.3)
47 (9.1)
6 (1.2)
446 (85.9)

Comparison over the years

Total treatment success, CBTP
Total treatment success, non-CBTP
Treatment failure, CBTP
Treatment failure, non-CBTP

2

2.38

0.12

0.59

0.44

18.00

0.01

4.50
0.38
6.07
6.68

0.11
0.83
0.05
0.04

CBTP  Community Based Tuberculosis Programme; Cured  smear-negative at the end of treatment; Treatment
completed  no bacteriological confirmation of cure; Treatment failure  smear-positive at 5 months or more after
the start of treatment; Died  patient died during treatment, whatever the cause of death; Defaulted  patient did
not attend for treatment for 2 consecutive months or more; Transferred out  transferred to a health care unit outside the district.

DISCUSSION
When short-course chemotherapy was introduced in
Central Sulawesi as part of a package which has been
known as the DOTS strategy since 1996, the first priority was to cure at least 85% of new smear-positive
patients diagnosed at health centres.2 The extension
of the strategy to hospitals and private practitioners
led to an increase in case-notification; however, fewer
than 50% of estimated smear-positive patients were
diagnosed and treated. Tuberculosis diagnosis and
treatment through case finding at health centres
and hospitals apparently does not become accessible
to part of the population living in rural areas.
By involving community health workers and community leaders, identification of tuberculosis suspects
and treatment of patients was made as accessible to the
patients as possible, and the communities assumed responsibility for patient adherence to treatment. Notification of new smear-positive patients more than tripled in the CBTP villages. Sputum conversion and
treatment success rates rose to over 85%, and, after the

CBTP was introduced, were even significantly higher

in the CBTP villages than in the non-CBTP villages.
We have no explanation for the decline in percentage of patients with positive smears at the end of the
first 2 months of treatment. The decline in percentage
of treatment failures may be related to the decline in
positive smear results at 2 months.
The strengths of the CBTP are that the programme
was based on observations by health workers that the
tuberculosis control services do not reach many people
in rural areas, and that it is implemented under routine field conditions. The weakness of the comparison
between CBTP and non-CBTP villages is that the villages were not selected randomly. Only after the
CBTP had been implemented did retrospective analysis of conversion rates and treatment results of 1996
and 1997 show that the differences between the
CBTP and non-CBTP villages were not statistically
significant and that comparison after implementation
of the CBTP was therefore justified.
During recent years, community involvement in
TB control has been given more attention. The in-

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The International Journal of Tuberculosis and Lung Disease

creasing number of tuberculosis patients with associated human immunodeficiency virus infection makes
clinic and particularly hospital care in many countries
no longer feasible.47 It is clear that the main role of
communities in tuberculosis care should be to ensure
patients adherence to treatment, consequently achieving high treatment success rates.810 In a recent publication, a summary is given of published studies describing community contribution to tuberculosis care.8
These studies exclusively concern delivery of treatment by a community worker, ranging from lay volunteers to village doctors. Satisfactory treatment results with 8090% success rates are reported. In other
studies, special groups of people, such as students,11
traditional healers,12 or TB clubs13 are used or recommended for observation of treatment.
Very little has been published about experiences
with the use of community leaders to raise awareness
about tuberculosis in communities. Raising community awareness about the signs and symptoms of a
disease and the availability of free diagnosis and
treatment has successfully been carried out by a variety of community leaders in the control of diseases
such as leprosy and malaria.1416
Because tuberculosis is often perceived as a chronic
incurable disease,16 increasing the awareness of signs
and symptoms of the disease and the possibilities for
cure is likely to increase the number of patients who
attend the services for diagnosis and treatment, as
was shown in Central Sulawesi. Prerequisites are that
the diagnostic services can cope with higher number
of smear examinations and that treatment for the increased number of diagnosed patients is guaranteed.
As an ongoing process, community participation is
likely to be sustainable, because community leaders
and health workers know the villagers. The following
lessons have been learnt from the experiences in Central Sulawesi:
Although DOTS had been implemented successfully in the entire province for 3 years, rural communities had little, if any, awareness about the
disease or the availability of free diagnosis and
treatment.
CBTP can substantially increase case notification
and ensure high treatment success rates.
Community participation may play an important
role in making progress to attain the WHO-recommended targets of detecting 70% of smear-positive
patients and curing 85% of them.
During 1999 and 2000 the CBTP was expanded. By
the beginning of 2001 it covered 561 (73%) of the
772 villages in the two districts. It has been further introduced in the two remaining rural districts and the
municipality, covering 66 (10%) of the 648 villages
by the beginning of 2001. It is the intention that by

the year 2005 CBTP will be implemented in all of the

villages in the province.
Acknowledgements
Our thanks go to the provincial and district Tuberculosis/Leprosy
supervisors, the staff of the participating health centres, and the
community leaders of the participating villages for their co-operation, dedication and enthusiasm. The help of Mr P Eilers with statistical analysis has been much appreciated.

References
1 World Health Organization. Global DOTS Expansion Plan.
Progress in TB control in high-burden countries, 2001. One
year after the Amsterdam Ministerial Conference. Geneva:
WHO, 2001.
2 Becx-Bleumink M, Djamaluddin S, Loprang F, de Soldenhoff R,
Wibowo H, Aryono, M. High cure rates in smear-positive tuberculosis patients using ambulatory treatment with once-weekly
supervision during the intensive phase in Sulawesi, Republic of
Indonesia. Int J Tuberc Lung Dis 1999; 3: 10661072.
3 Enarson D, Rieder H, Arnadottir T, Trbucq A. Tuberculosis
guide for low income countries. Fourth ed. Paris, France:
IUATLD, 1996.
4 Maher D, Hausler H P, Raviglione M R, et al. Tuberculosis care
in community care organizations in sub-Saharan Africa: practice
and potential. Int J Tuberc Lung Dis 1997; 1: 276283.
5 Squire S B, Wilkinson D. Strengthening DOTS through community care for tuberculosis. BMJ 1997; 315: 13951396.
6 Banerjee A, Harries A D, Mphasa N, et al. Evaluation of a unified treatment regimen for all new cases of tuberculosis using
guardian-based supervision. Int J Tuberc Lung Dis 2000; 4:
333339.
7 Wilkinson D. High-compliance tuberculosis treatment programme in a rural community. Lancet 1994; 343: 647648.
8 Maher D, van Gorkom J L C, Gondrie P C F M, Raviglione M.
Community contribution to tuberculosis care in countries with
high tuberculosis prevalence: past, present and future. Int J Tuberc Lung Dis 1999; 3: 762768.
9 Akkslip S, Rasmitat S, Maher D, Sawert H. Direct observation
of tuberculosis treatment by supervised family members in
Yasothorn Province, Thailand. Int J Tuberc Lung Dis 1999; 3:
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10 Kamolratanakul P. Randomized controlled trial of directly observed treatment (DOT) for patients with pulmonary tuberculosis in Thailand. Trans R Soc Trop Med Hyg 1999; 93:
552557.
11 Rajeswar R, Chandrasekan K, Thiruvalluvan E, et al. Study of
the feasibility of involving male student volunteers in case
holding in an urban tuberculosis programme. Int J Tuberc
Lung Dis 1997; 1: 573575.
12 Wilkinson D, Gcabashe L, Lurie M. Traditional healers as
tuberculosis treatment supervisors: precedent and potential.
Int J Tuberc Lung Dis 1999; 3: 838842.
13 Getahun H, Maher D. Contribution of TB clubs to tuberculosis control in a rural district in Ethiopia. Int J Tuberc Lung Dis
2000; 4: 174178.
14 Kumar A, Thangavel N, Durgambal K, Anabalagan M. Community leaders involvement in leprosy health education. Int J
Lep 1984; 56: 901911.
15 Garfield R, Vermund S H. Health education and community
participation in mass drug administration for malaria in Nicaragua. Soc Sci Med 1986; 22: 869877.
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control: lessons from other health care programmes. Int J Tuberc Lung Dis 2000; 4: 401408.

TB control through community participation

925

RSUM
C A D R E : La Province Centrale de Sulawesi, Rpublique
dIndonsie.
O B J E C T I F : Augmenter le taux de dclaration des cas de
tuberculose et maintenir des taux levs de succs du
traitement grce la participation de la collectivit un
programme de tuberculose sur le terrain.
S C H M A : Comparaison des dclarations des cas de tuberculose et des rsultats du traitement dans un programme bas sur la collectivit (CBTP), respectivement
avant et aprs lintroduction du programme ainsi quentre les zones o le programme tait ou ntait pas mis en
uvre.
R S U L T A T S : Au cours de lanne 1998, le CBTP a t
introduit dans deux des quatre districts ruraux de la
Province centrale du Sulawesi et a couvert 224 (29%)
des 772 villages et 362.700 (33%) des 1.109.100 habitants de ces districts. Dans les villages CBTP, le taux de
dclaration des nouveaux patients bacilloscopie positive pour 100.000 habitants a augment de 51 au cours
de lanne 1996 et 48 au cours de 1997 jusque 166 pen-

dant lanne 1998. Dans les 548 villages non-CBTP, les

taux taient respectivement de 62, 60 et 70. Le taux de
ngativation de lexpectoration la fin des deux premiers mois de traitement tait suprieur 85% tant dans
les villages CBTP que dans les villages non-CBTP. Dans
les villages CBTP, les taux de succs du traitement
(gurison ou achvement du traitement) taient respectivement de 90,4%, 89,5% et 93,7% au cours des
annes 1996, 1997 et 1998. Pour les villages non-CBTP,
ces taux taient respectivement de 85,4%, 86,8% et
85,9%. Au cours de lanne 1998, les taux de ngativation de lexpectoration et de succs du traitement sont
significativement plus levs dans les villages CBTP que
dans les villages non-CBTP.
C O N C L U S I O N : Grce la participation de la collectivit,
la dclaration des nouveaux cas de tuberculose bacilloscopie positive a augment de faon substantielle alors
que les taux de ngativation et les taux de succs du
traitement restaient levs.

RESUMEN
M A R C O D E R E F E R E N C I A : Provincia Central de Sulawesi, Repblica de Indonesia.
O B J E T I V O : Aumento en la notificacin de casos de
tuberculosis y mantenimiento de altas tasas de xito teraputico a travs de la participacin de la comunidad en
un programa de tuberculosis de campo.
M T O D O : Comparacin de la notificacin de casos de
tuberculosis y de los resultados del tratamiento en un
Programa de Tuberculosis Basado en la Comunidad
(PTBC), antes y despus de la introduccin del programa y entre reas con y sin programas.
R E S U L T A D O S : Durante 1998 el PTBC fue introducido
en dos de los cuatro distritos rurales de la provincia Central Sulawesi, cubriendo 224 (29%) de 772 aldeas y
362.700 (33%) de los 1.109.100 habitantes de estos distritos. En las aldeas con PTBC la tasa de notificacin de
los nuevos pacientes con baciloscopa positiva por cada
100.000 habitantes aument de 51 durante 1996 y 48 en

1997, a 166 en 1998. En las 548 aldeas sin PTBC las

tasas fueron 62, 60 y 70, respectivamente. La tasa de
conversin del esputo al final de los primeros 2 meses
de tratamiento estuvo por encima del 85% en las aldeas
con PTBC, as como en las aldeas sin PTBC. En las aldeas con PTBC las tasas de xito teraputico (curacin y
tratamiento completo) fue del 90,4%, 89,5% y 93,7%
durante 1996, 1997 y 1998, respectivamente. En las aldeas sin PTBC las tasas fueron 85,4%, 86,8% y 85,9%.
En 1998 las tasas de conversin del esputo y del xito
teraputico fueron significativamente ms altas en las aldeas con PTBC que en las que no lo tenan.
C O N C L U S I N : La notificacin continuada de la participacin de la comunidad de los pacientes con esputo
positivo aument substancialmente, mientras que la
conversin de los esputos y los xitos teraputicos permanecieron altos.