Journal of the National Institute of Public Health2012 Vol.61 No.4 p.357−365＜Original＞
Community-involved strategy to improve tuberculosis (TB)
treatment outcomes in Eastern Region of Ghana
Samuel Agyemang BOATENG１，２），Tomoko KODAMA３），Fumihiro SATA４），
George BONSU５），Eri OSAWA６）
１）

Eastern Regional Health Administration, Ghana
Central Tuberculosis Unit, Accra. Ghana
３）
Guest Researcher, Department of International Health and Collaboration, National Institute of Public Health, Japan(ex-Chief Senior Researcher, Department of International Health and Collaboration, National Institute of Public
Health, Japan)
４）
Department of Environmental Health, National Institute of Public Health, Japan
５）
Eastern Regional Health Adminigtration, Kotoridua, Ghana
６）
Department of International Health and Collaboration, National Institute of Public Health, Japan

２）

Abstract
Objective: To evaluate decentralization and community supervision of tuberculosis treatment as an effective intervention to
improve treatment outcomes in Eastern Region of Ghana.
Methods: A historical comparison of treatment outcomes of cohorts registered in 2003-2005 with centralized Directly
Observed Treatment short course (DOTs) at health facility level and cohorts registered in 2007-2009 with decentralized DOTs
at the community level. Effectiveness was measured by comparing TB case finding and treatment outcomes before and after
the introduction of the decentralization with participation of local communities providing the option of treatment supervision.
Results: In total 5128 cases were registered during the centralized period with 60% being men and 40% women. In thedecentralized period 5309 cases were recorded with 62.7% men and 37.3% women. Among new smear-positive cases there wasa significant difference between treatment success rates in the decentralized period as compared to the centralized period(82.7% vs 69.6%, respectively: p-value < 0.0001). Cured rate improved during the decentralized period as against the centralized
period (75.8% vs 63.2%, respectively; p-value < 0.0001). Defaulter rate significantly reduced in the decentralized period ascompared to the centralized period (3.6% vs 12.1%, respectively; p-value < 0.0001). Among new smear negative-and extra
pulmonary TB patients, treatment completion rate was significantly higher in the decentralized period than in the centralized
period (80.2% vs 56.3%, respectively; p-value < 0.0001) and defaulter rate was significantly reduced in the decentralized period
than in the centralized period (3.3% vs 17.7%, respectively; p-value < 0.0001)
Conclusion: Decentralization of TB treatment to the community level, empowering TB patients to choose treatment
supporters from the community and communities providing treatment supervision till cure, improved treatment outcomes in
Eastern Region of Ghana.
keywords: tuberculosis (TB), decentralize, centralize, treatment outcome, Eastern Region and Ghana.
(accepted for publication, 25th June 2012)

Ⅰ．Introduction
One of the challenges facing the health systems is tobring the provision of health services as close as possible tothose who need them. The need to promote community
contribution to tuberculosis (TB) care as part of National

Tuberculosis Programme (NTP) activities is particularly
urgent in Sub-Sahara Africa, where the humanimmunodeficiency virus (HIV) is fuelling the TB
epidemic [1-3].
Eastern Region of Ghana had a projected population of
2,420,927 with a growth rate of 1.4% (2000 National census).
It is the sixth largest region in Ghana with a land area of

Samuel Agyemang BOATENG
E-mail: unikpharmacy@yahoo.com

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Samuel Agyemang BOATENG，Tomoko KODAMA，Fumihiro SATA，George BONSU，Eri OSAWA

19,323 sq. km., thus representing about 8% of the total landarea of the country and 11.5% in terms of population.
The region with its capital Koforidua (New Juaben) isbounded on the East by the Volta Region, South by Greater
Accra region, West by Central Region and on the North by
Ashanti Region as shown in figure 1. The Eastern Region
has 21 districts and a total of 136 sub-districts as shown infigure 2. There are 23 hospitals, 53 health centres, 126
Reproductive and Child Health (RCH) centres, 502
demarcated Community-based Health Planning Services(CHPS) compounds, 135 functional CHPS and 26 TB
diagnostic centres. A rapid assessment of National
Tuberculosis Control programme conducted in Koforidua(New Juaben) revealed that defaulter rate in the district wasover 40% [4]. A cross-sectional study carried out in 2006 to
elicit factors contributing to high tuberculosis treatment
default rate in New Juaben came out that long distancefrom home to treatment centre (Odds Ratio; OR 6.14), poorfamily/community support (OR 3.43), lack of financial
support (OR 4.14, poor attitude of staff (OR 2.72), lack ofknowledge and long treatment duration (OR 2.83) weremost influential contributing factors to default [5]. With
Such challenges several studies have shown that
decentralization of tuberculosis treatment, offering patientsthe option of treatment supervision in the community andwith the necessary support, communities have the potential
to contribute to TB care and improve treatment
outcomes [6-15]. This necessitated the need to decentralized
tuberculosis treatment, which is moving tuberculosis

Figure 1 Map of Ghana Showing the ten Regions.

Figure 2 Map of Eastern Region Showing the 21 Districts.

358

J. Natl. Inst. Public Health, 61（4）: 2012Community-involved strategy to improve tuberculosis (TB) treatment outcomes in Eastern Region of Ghana

treatment care from health facility level to the community
level to enable community members’ offer their support
and care to TB patients in order for their treatment
outcomes to be improved.

Ⅱ．Methods
Study Design: Historical comparisons of the treatment
outcomes: a) Cohorts registered in 2003-2005 withcentralized DOTs at health facility level; b) Cohort
registered in 2007-2009 with decentralized DOTs at thecommunity level
Preparation for decentralization: Stakeholders
meetings were held for the Regional Health Directorate(RHA) members, District Directors of Health Services(DDHS) and National Tuberculosis Programme (NTP) tosolicit for their support.
Meetings were held for community opinion leaders,
community members, Chiefs and elders, organized groups
like Ghana Private Road Transport Unions (GPRTU),
Chemical sellers groups and other key community
members. Several community durbars were also held todiscuss the essence of the study and the roles ofcommunity members.
Trainings were conducted for health staff, District TB
Coordinators (DTC), laboratory staff and community
volunteers and final year nursing training school students
since they will soon complete and join the health service.
Ethical Consideration: Permission was sought fromthe Regional Director of Health services and NTP to
conduct the study in Eastern Region. Patients’ oral or
written consent form was agreed or signed before a patientis rolled into the study.
Sputum collection and microscopy: Laboratory staffs
from the 26 diagnostic centres were given training in
sputum smear microscopy. All TB suspects reporting to any
health facility at the Sub-district level were referred to these
diagnostic centres for sputum smear microscopy withlaboratory request form fully filled.
A patient with persistent cough for two weeks or morewith fever, weight loss, and night sweat, sputum with blood
stain, chest pain and difficulty in breathing or in case of
HIV positive coughing for 24 hours or more was said to be a
TB suspect
Patients were educated on how to produce sputum by
clearing the back of the throat and cough but not spit.
Three sputum samples (spot-early morning-spot) werecollected for sputum smear microscopy from each patient inplastic containers with specimen identification numbers.
Slides were prepared from each sputum, fixed and stainedwith Zeil-Neelsen solution, decolorized with 25% H2SO4 andcounter- stained with 0.3% methylene blue. Degree ofMycobacterium infection was assessed by counting thenumber of bacilli at magnification 750X. Precautions weretaken to avoid contamination as this could lead to false
results [16].
Patients on treatment also had their sputum conversion
follow ups done on months 2, 5 and 6 for all new TB
patients and for re-treatment patients on months 3, 5 and 8.
Treatment Regimen: A new treatment regimen was
introduced as a result of new drug formulation called Fixed
Dose Combination formulation [17], where two or four
drugs have been combined to form a single tablet for a dose
(HRZE= I Tablet, HR=1 Tablet). Additionally there was no
streptomycin injection for new cases. All patients who had
never taken TB treatment or had taken TB treatment forless than one month were considered as new patient. A newpatient may have positive or negative bacteriology and may
have the disease at any anatomical site (new smear-positive
Pulmonary TB; new smear negative pulmonary TB, newextra pulmonary TB). Patients who had previously received
TB treatment for one month or more were considered aspreviously treated TB patients. A previously treated TB
patient may also have positive or negative bacteriology andmay have the disease at any anatomical site. They were
further classified by the outcome of their most recent
course of treatment as Relapse, Treatment failure andTreatment after interruption.
Treatment duration was six months for all new patientswith initial phase of 2 months and continuation phase forfour months. Treatment duration for all previously treatedpatients was eight months with initial phase of 3 months
and continuation phase of 5 months.
The drugs were put into categories according to thepatients classifications. Category I drugs for all new
patients, Category II drugs for previously treated patientsand Category III drugs for children less than 12 year. The
prescribed dosage was based on four weight bands for
adults and children but not according to age groups.
Drug distribution: All anti-tuberculosis drugs were
kept at the Regional Medical Stores (RMS). Drugs supplies
to the districts were based on the district TB case-load
reported in the previous quarter and the District TB
coordinator supplied the drugs to all the sub-districts healthfacilities. The TB treatment supporters collected theirdrugs from their respective areas every two weeks in theinitial phase and monthly in the continuation phase. The
treatment supporter tallied all doses of drugs given to thepatient under Directly Observed Treatment (DOT) in atreatment supporter’s card. The chain of distribution ofdrugs was usually reliable to TB treatment supporter as thedrugs come as patient Kit and blister form meant for full

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Samuel Agyemang BOATENG，Tomoko KODAMA，Fumihiro SATA，George BONSU，Eri OSAWA

treatment of the patient.
Home verification: All patients diagnosed as having TB
were referred to their nearest health facility with a referralnote and the community health officer in the area conduct
home verification by visiting the home of the patient toverify: The home address of the patients
 Number of rooms in the house Number of people living in the same room with thepatient
 If there is cross ventilation in the room If the compound is hygienic
 Type of meal often eaten by the people and thecontacts
 Contacts in the house having sign and symptoms of
TB
 Contacts in the house having signs and symptoms ofHIV All children less than six years living in the same
house with the TB patient.
All contacts who were found to be having signs andsymptoms of TB or HIV or both were referred to the
district hospital for assessment by a clinician.
Options for DOTs: Very ill patients or those with social
problems were admitted at the main hospital. The healthfacility staff gave the patients the opportunity to choose atreatment supporter from the community where he/she
lives. The treatment supporter can be a community
volunteer, family member or a health staff if the patient
lives close to the health facility. The TB patient had the final
word in choosing their DOT option. Both the TB patient
and the treatment supporter were then educated on TB andHIV with regards to causes, mode of transmission,
treatment, follow up for sputum, side effects of drugs andpreventive measures. They were also made to understandthat treatment is free.
The role of TB treatment supporter: The role and the
responsibilities of a treatment supporter were to collect thetablets on monthly or weekly basis, and store them safely.
Directly observing the intake of tablets (in the rightnumber of drugs and dosage), recording the daily intake ofdrugs in the treatment supporter card, encouraging thepatient to attend the health centre and hospital/clinic forfollow up as required. Identifying possible side effect andrefer to the health facility if necessary. They help thepatient to overcome difficulties to continue the treatment
and identifying the patient who does not arrive for supportand help trace and retrieve them.
Supervision of community TB treatment supporter:
The community health officer (CHO) in the community
supervises the TB treatment supporter in facilitating360

treatment completion by the patient and is responsible for
ensuring an effective relationship between patient andtreatment supporter. The treatment supporter reports to
the Sub-district health facility for advice and renewal of thedrugs.
Registering TB patients: All diagnosed TB patientswere classified and assigned to the correct patient
treatment groups. All details of the patients were enteredinto the Institutional and District TB registers. In addition
patients who were being treated at the community level
were registered in the community health officers’ register.
TB/HIV collaborative activities including referralmechanism: All TB suspects were screened and counseledfor HIV. They were offered testing and those who werereactive were referred to the Anti-retroviral Therapy (ART)clinic and put on ART and co-trimoxazole prophylaxis(CPT) if needed. All HIV clients were screened for TB
using a TB screening tool at the Anti-retroviral Therapy
clinic and those found to be TB suspects referred to DOTs
centre for further investigations.
Quality Assurance (sputum microscopy): Quality
control (internal quality assurance), external assessment
and blinded re-checking were done in all the 26 diagnostic
centres. Feedback of assessment of smear preparation,
grading and bio-safety were given to all facilities concerned.
Thirty five laboratory officers were trained in QA sputum
microscopy.
Outcome measures: Assessment outcomes of patients
either being successfully treated or not were grouped into
cured, treatment failure, treatment completed, defaulted,
transfer out or died and properly documented in thepatient’s treatment card.
 Cure: Sputum smear positive (+) patient who is
sputum smear negative (-) in the last month oftreatment and at least once before.
 Treatment completed: Patient who has completed
treatment but does not meet the criteria to beclassified as cured or a failure.
 Default: Patient whose treatment was interrupted for
2 consecutive months or more.
 Died: Patient who dies from any cause during thecourse of treatment.
 Treatment failure: New patient who is sputum smear
positive (+) at months 5 or later during the treatment
or a previously treated patient who is sputum smear
positive (+) at the end of his retreatment.
 Transfer out: Patient who has been transferred toanother recording and reporting unit for whom
treatment outcome is not known.
Data collection and analysis: The district TB
coordinators visited all the sub-district health facilities twice

J. Natl. Inst. Public Health, 61（4）: 2012Community-involved strategy to improve tuberculosis (TB) treatment outcomes in Eastern Region of Ghana

every month and collected all the TB data for analysis. A
data clerk at the regional level assisted in the collection of
the data and entered them into MS Excel and analyzed.
Statistical significance of treatment outcomes were tested
by using Chi-square at 5% significance level.

Ⅲ．Results
Case-finding:
Table 1 shows all TB cases detected by categories. The
number of TB cases (all forms) recorded for the centralized
period (2003-2005) and the decentralized period (20072009) were 5128 and 5309, respectively. There was no
significant difference in the proportion of smear positive TB
cases detected in the centralized period as against thedecentralized period. The majority of TB patients in boththe centralized and the decentralized periods were newsmear-positive pulmonary (2927 and 3044 patients,
respectively). The proportion of males was larger thanfemales in both the centralized (60%) period and thedecentralized (62.7%) period. It was observed that the
proportion of TB infection was large in the age groups of 2534 (23.3% vs 21.5% in the centralized period and thedecentralized period, respectively) and 35-44 years (30% vs
23.8% in the centralized period and the decentralized period,
respectively) among new smear-positive pulmonary TB
cases.
Table 2 shows the annual treatment outcomes for thecentralized period and the decentralized period among new
smear-positive pulmonary, smear-negative and extrapulmonary TB patients.
Treatment outcomes:
Table 3 shows a comparison of treatment outcomes

between the centralized period and the decentralized
period. There was a significant difference between
treatment success rates for new smear-positive pulmonary
TB cases in the decentralized period as compared to thecentralized period (82.7% vs 69.6%, respectively; p-value <0.0001) and the proportion of patients who were cured
improved during the decentralized period as against thecentralized period (75.8% vs 63.2%, respectively; p-value <0.0001). Regarding smear-negative and extra-pulmonary
TB patients, the proportion of patients who completed
treatment was significantly higher in the decentralized
period than in the centralized period (80.2% vs 56.3%,
respectively; p-value < 0.0001), and the proportion ofpatients who defaulted was significantly lower (3.3% vs17.7%, respectively; p-value < 0.0001) in the decentralized
period than in the centralized period. The proportion of
new smear-positive pulmonary TB patients who defaulted
was significantly reduced in the decentralized period ascompared to the centralized period (3.6% vs 12.1%,
respectively; p-value < 0.0001). Few proportion of patientswere transferred from one reporting unit to another in thedecentralized period as against those in the centralized
period (3.1% vs 7.3%, respectively; p-value < 0.0001) among
smear pulmonary positive patients. There was no
significant difference in other treatment outcomes (failed
and died) among new smear sputum positive pulmonary TB
patients.
There was much lower proportion of smear-negative andextra-pulmonary TB patients who were transferred fromone reporting unit to another in the decentralized period
than in the centralized period (2.7% vs 12.9%, respectively; pvalue < 0.0001) and there was no significant difference
between patients who died during the decentralized period

Table 1 TB case finding for centralized period (2003-2005) and decentralized period (2007-2009)

year

2003
Centralized
period

2004
2005
Total
2007

Decentralized
period

2008
2009
Total

Total
n (%)
1719
(100)
1665
(100)
1744
(100)
5128
(100)
1669
(100)
1737
(100)
1902
(100)
5308
(100)

New
smear
positiven (%)
1002(58.3)
923(55.4)
1002(57.5)
2927(57.1)
978(58.6)
1019(58.7)
1047(55.0)
3044(57.3)

New
smearnegative
n (%)
550
(32.0)
522(31.4)
557(31.9)
1629(31.8)
536(32.1)
516(29.9)
661(34.8)
1713(32.3)

New
EPTB
n (%)
97
(5.6)
129
(7.7)
87
(5.0)
313
(6.1)
70
(4.2)
98
(5.6)
116
(6.1)
284
(5.4)

Re-treatment
smearpositive
n (%)
70
(4.1)
91
(5.5)
98
(5.6)
259
(5.1)
85
(5.1)
104
(6.0)
78
(4.1)
261
(5.0)

HIV
HIV
HIV
at HIVCounseled Tested Positive Clinic

on
ART

on
CPT

0

244

82

0

25

77

1326

1076

364

221

113

328

1630

1498

381

279

109

372

2956

2818

827

500

247

777

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Samuel Agyemang BOATENG，Tomoko KODAMA，Fumihiro SATA，George BONSU，Eri OSAWA
Table 2 Treatment outcomes for centralized period (2003-2005) and decentralized period (2007-2009)
year
2003
New smear sputumpositive pulmonary TB

2004
2005
Total

Centralized
period2003
new sputum smearnegative pulmonary
and extra pulmonary
TB

2004
2005
Total
2007

New smear sputumpositive pulmonary TB

2008
2009
Total

Decentralized
period2007
new sputum smearnegative pulmonary
and extra pulmonary
TB

2008
2009
Total

Treatmentcompleted
n (%)

Total
n (%)

Cure
n (%)

1041
(100)
923
(100)
1012
(100)
2976
(100)
647
(100)
403
(100)
607
(100)
1657
(100)
999
(100)
1002
(100)
1025
(100)
3026
(100)
629
(100)
660
(100)
769
(100)
2058
(100)

600
(57.6)
616(66.7)
660(65.2)
1876(63.2)

74
(7.1)
58
(6.3)
60
(5.9)
192
(6.4)
346
(53.5)
231(57.3)
354(58.3)
931(56.3)
58
(5.8)
74
(7.4)
76
(7.4)
208
(6.9)
481
(76.5)
541(82.0)
632(82.2)
1654(80.2)−−−−
742(74.3)
767(76.5)
784(76.5)
2293(75.8)−−−−

Failed
n (%)

Died
n (%)

Defaulted
n (%)

Transfer
n (%)

19
(1.8)
9
(1.0)
16
(1.6)
44
(1.5)

111
(10.7)
76
(8.2)
99
(9.8)
286
(9.6)
87
(13.4)
44(10.9)
89(14.7)
220(13.0)
83(8.3)
105(10.5)
88
(8.6)
276
(9.1)
97
(15.4)
95(14.4)
88(11.4)
280(13.7)

151(14.5)
105(11.4)
104(10.3)
360(12.1)
123(19.0)
76(18.9)
92(15.2)
291(17.7)
43
(4.3)
22
(2.2)
43
(4.2)
108
(3.6)
19
(3.0)
15
(2.3)
36
(4.7)
70
(3.3)

86
(8.3)
59
(6.4)
73
(7.2)
218
(7.3)
91
(14.1)
52(12.9)
72(11.9)
215(13.0)
58
(5.8)
16
(1.6)
21
(2.0)
95
(3.1)
32
(5.1)
9
(1.4)
13
(1.7)
54
(2.7)

−
−
−
−
15
(1.5)
18
(1.8)
13
(1.3)
46
(1.5)
−
−
−
−

Table 3 Comparison of treatment outcomes for centralized (2003-2005) and decentralized (2007-2009) period

New smear sputum-positive
pulmonary TB

new sputum smear- negative
pulmonary and extra
pulmonary TB

Outcome of treatment

Centralized period (%)

Decentralized period (%)

p-value*

Cure

63.2

75.8

< 0.0001

Treatment completed

6.4

6.9

0.512

Failed

1.5

1.5

0.894

Died

9.6

9.1

0.515

Defaulted

12.1

3.6

< 0.0001

Transfer

7.3

3.1< 0.0001

Success(cure and completed)

69.6

82.7

< 0.0001

Treatment completed

56.3

80.2

< 0.0001

Died

13.0

13.7

0.771

Defaulted

17.7

3.3

< 0.0001

Transfer

12.9

2.7

< 0.0001*Chi-square test

and the centralized period (13.7% vs 13.0%, respectively; pvalue = 0.771) among new sputum smear pulmonary andextra pulmonary TB patients.
TB/HIV collaborative activities: There was no such

362

activity during the centralized period and hence there wasno data for such activity. Data collection started in quarter 4of 2007 as shown in table 1.

J. Natl. Inst. Public Health, 61（4）: 2012Community-involved strategy to improve tuberculosis (TB) treatment outcomes in Eastern Region of Ghana

Ⅳ．Discussion
The community involved strategy and decentralization of
TB care in Eastern Region proved to be a highly effective
and acceptable alternative to conventional TB care that
relies completely on health facility provision of TB care. In
the face of decreasing government resources for health andan increasing TB case-load fuelled by HIV, Eastern Region
was able to successfully decentralized TB treatment to thecommunity level and this reduced the workload on healthstaff as ample time gained was used to manage otherequally important activities at the facilities.
The key findings of this study were that TB cases
detected (all forms) increased during the decentralized
period: 1670 (in 2007), 1737 (in 2008), 1902 (in 2009)
making a total of 5309 as against the centralized period 1719
(in 2003), 1665 (in 2004), 1744 (in 2005) making a total of
5128, but case-finding among smear-positive pulmonary TB
cases stagnated for both the decentralized period and thecentralized period 978 (in 2007 ) , 1019 (in 2008), 1047 (in2009) vs 1002 (in 2003), 923 (in 2004), 1002 (in 2005),
respectively. The 26 diagnostic centres in the region are
woefully inadequate to cater for a population of 2,420,927(2000 census). It is therefore recommended that morediagnostic centres should be opened so that suspected TB
cases can easily have access to diagnostic services and ontime to avoid delays. It was also observed that diagnostic
services and TB care can only be accessed from publichealth facilities and it is therefore long overdue to bring theprivate health care providers on board to improve TB casedetection and management which will lead to improved
treatment outcomes. Several studies showed that PublicPrivate Mix DOTs (PPM-DOT) has the potential to improve
TB case detection and treatment outcomes [18-21].
Majority of TB patients in both periods were new smearpositive pulmonary TB patients. Treatment success which
was significantly higher in the decentralized period than in
the centralized period (82.7% vs 69.6%, respectively; p-value< 0.0001) may be attributed to a lot of factors which include
the fact that TB treatment was successfully decentralized tothe door steps of the TB patients. The involvement of thecommunity volunteers, treatment supporters, health staff,
opinion leaders and other key stakeholders in the earlystage of planning and implementation facilitated thedecentralization process. The introduction of new drug
formulation where many drugs have been fused into asingle tablet (fixed dose combination) made it easy for TB
patients to ensure proper compliance during thedecentralized period. The removal of streptomycin injection
which was replaced with Ethambutol in the new treatment

for new cases during the decentralized period also
facilitated the decentralization process that is, TB patients
do not have to commute to the health facility every day forthe injection. This also saved the patients the economic
hardship of transport fares and the long distance to thehealth facility every day. As the drugs were packed in kits
for the full treatment duration, drug stock out was thing of
the past during the decentralized period. The treatment
duration which was shortened as a result of the new drug
formulation was also a contributing factor to the hightreatment success during the decentralized period.
{2(HRZS)+6HT
centralized
versus2(HRZE)+4HR
decentralized for new cases} and 12(HRZE) centralized
versus 2(HRZES)1HRZE +5(HRE). Defaulter rate dropped
significantly from 12.1% to 3.6% during the centralized anddecentralized periods, respectively (p-value < 0.0001) andthis could be attributed to the above mentioned factors andthe close monitoring of the patients by treatment
supporters. Transfer out dropped from 7.3% to 3.1% during
the centralized and decentralized periods and this was dueto the fact that TB patients had access to TB treatment andcare in the community where he or she lives. For smearnegative pulmonary and extra pulmonary TB cases
treatment completed, defaulter rate and transfer out
significantly improved during the decentralized period thanin centralized period. One alarming observation was the
proportion of TB patients who died before completing
treatment. Such a high TB deaths makes it difficult or
impossible to achieve the 85% WHO target for treatment
success. It is therefore recommended that TB deaths
should be audited to elicit the true cause of death.
Advantages of decentralizing TB care were that, thetraining of health staff, volunteers, treatment supporters
and community members resulted in increase awareness,decreased stigma, improved documentation, monitoring,supervision and a more educated population. Many persons
became more motivated seeing the initial success incommunity involvement in TB care and witnessingcures among TB patients. The communities’ leaders
acknowledged the immense contribution these people were
putting in TB care and respected them as such. Choosing
volunteers rather than the family was exceedingly
beneficial because of the immediate, direct involvement of
the community in such a key public health issues. As aresult of high commitment of the treatment supporters tocare for TB patients, most TB patients agreed to stay attheir homes and received TB care and this reduced transfer
outs which mostly were declared defaulters during thecentralized period. TB patients also became motivated tocomplete their treatment as a result of the inspirational
words and care they received from their treatment

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Samuel Agyemang BOATENG，Tomoko KODAMA，Fumihiro SATA，George BONSU，Eri OSAWA

supporters. Other advantage of the decentralized TB care
was that it increased the human resource base for TB
control as compared to the centralized TB care where only
health staffs were involved.
The disadvantage of decentralizing TB care was that incommunities where members could not keep confidential
issues, community involved strategy does not work.
TB/HIV collaborative activities immensely improved
management of co-morbidity patients and this can be alearning process for HIV programme to follow suit since
this will prevent lost to follow up patients which are
increasing in the HIV control.
Limitations:
The study could not separate the effect ofdecentralization and the new drug formulation andtreatment regimen. Also the study could not elicit thecauses of TB deaths and which phase of treatment these
deaths occurred. There was no data on population ofEastern Region on age groups and to determine theprevalence of TB infection in the different age groups andsex.

Ⅴ．Conclusion
The community involved strategy and decentralization of
TB care with empowering people with TB to choose
treatment supporters from their communities, communities
to provide effective TB care by supporting TB patients
throughout treatment until cure, reducing treatment
duration and the use of fixed dose combination drugs canimmensely improve treatment outcomes. It is therefore
recommended that community-involved strategy in TB
control should be scaled up to other regions in the country.

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