Lessons from research in Bangladesh
- It is feasible to engage garment factories in TB control activities, thereby increasing case notifications and improving treatment outcomes
- Raising awareness about TB treatment protocols is important if factory managers are to allow TB patients to get their treatment during working hours
- Dedicated advocacy, communication and social mobilisation activities create awareness among workers and help change the attitudes and practices of factory managers and supervisors.
- The Public-Private Partnership (PPP)-TB workplace model provides an example of a multi-stakeholder, programme-based approach to tackle TB care
- Engaging the business sector in organising TB treatment and supervision works best when it is tailored to a specific group
- The principles of PPP offers a sustainable solution for providing healthcare in the workplace, but needs to be adapted to different workplace contexts
The issue: TB in the workplace
The Bangladesh garment manufacturing sector is a significant employer, with over 3500 factories employing 4 million workers, 80% of whom are poor, young women.1–2 Workers in the garment industry are vulnerable to TB. The workplace setting increases their risk of catching TB due to occupational exposure and cramped working conditions. Workers also face the possibility of losing their job, and discrimination from employers. For the worker, the workplace is an ideal place to gain awareness of and receive treatment for TB.
For the garment factory, a sick worker means disrupted workflow, reduced productivity, and weeks or months of absenteeism. Workplace TB care services can therefore save costs by reducing absenteeism and staff turnover through prompt diagnosis and treatment, and by reducing TB transmission to other workers.
Managing TB in the workplace therefore presents a win-win situation for both workers and garment factory owners.
The garment industry in Bangladesh
The Bangladesh Garment Manufacturers and Exporters Association (BGMEA) is one of the largest trade associations representing the readymade garment industry in Bangladesh. The association is also committed to ensuring workers’ rights and social and environmental standards in factories. It runs 7 health centres in Dhaka City.
Developing the partnership
The National TB Control Programme (NTP), BGMEA and partner NGOs were involved at every stage in developing service links, operational guidelines, referral tools, training material and in monitoring and evaluating the research intervention. This approach helped develop their capacity and also helped create ownership amongst the partners for implementing the TB control programme on a larger scale. We embedded the research with the NTP’s existing TB activities, which included using the WHO-recommended Directly Observed Treatment (DOT) strategy.
We formed a Technical Working Group Committee (TWGC), with representatives of the partners and private medical practitioners, to advise on operational issues. The TWGC, acting within the scope of the NTP, helped design the intervention, contributed to developing the implementation materials, and provided technical guidance to the research team. We also included private medical practitioners who had established service links with the NTP and were located close to the garment factories.
Impact of the research
The research has brought positive changes in knowledge, attitudes and practices of managers, workers and healthcare providers on TB care and control.
598 workers were diagnosed positive for TB. 145 received treatment at the factory and completed their scheduled treatment as per the NTP guidelines; a success rate of 100%. 453 received treatment from NGO-run DOTs centres; a success rate of 85-89%
Factory managers are now aware of the TB treatment protocol, and now allow TB patients to receive treatment during working hours, without any wage cut. They also allow their workers paid and/or unpaid leave for up to 30 days with the assurance of a job when they return to the factory
Medical staff in the garment factories refer the TB patient to DOTs centres, and maintain patient records
Workers are now aware of the symptoms of TB, the availability of free anti-TB treatment at DOTs centres, and of the adverse effects of discontinuing their treatment. They felt able to seek diagnosis and treatment without fearing dismissal
The project developed record-keeping processes to track patients at every stage of treatment. The referral slip and treatments cards have been adopted by the NTP and are now used nationally
Before the research
The NTP diagnosis centres, private medical practitioners, garment factories and their workers had no links. No garment workers were recorded at
factory clinics as being suspected of TB, diagnosed with TB or referred
elsewhere for diagnosis.
Our PPP model allowed garments factories to refer workers to designated TB diagnosis centres, including private medical practitioners, for sputum testing. If the workers tested positive for TB, they were either sent back to their respective garment factories where medical facilities were available, or were treated at the NTP-run NGO clinics for free.
We developed 3 approaches for the 3 different levels of health provision we found at the factories. We incorporated private medical practitioners into 2 of these approaches (see figure in PDF version).
After the intervention
There were clear referral links after our intervention, a 100% success rate for all TB patients at the large and medium-sized factories, and a 85-89% success rate for TB patients at small factories.
For more information email Dr Rumana Huque: firstname.lastname@example.org
This brief is based on the following evidence:
Zafar Ullah A N, Huque R, Hossain A, Akter S, Akter H, Newell J N. (2012) Tuberculosis in the workplace: developing partnerships with the garments industries in Bangladesh. International Journal of TB and Lung Diseases. 16(12): 1637-1642. doi.org/10.5588/ijtld.12.0378
- Huque R, Ahmed S, Jahan N A, Sultana N. (2003) Introduction of health insurance scheme for the improvement of health status of the garment workers in Bangladesh: a study of selected garment factories. Research Report 11. Dhaka, Bangladesh, Institute of Health Economics, University of Dhaka
- World Health Organization. (2007) Assessment of tuberculosis control activities in workplaces in Chittagong and Dhaka, Bangladesh. Mission Report. Geneva, Switzerland: WHO