Conflicting accountabilities: Doctor's dilemma in TB control in rural India

The aim of this study was to analyse how the implementation strategy of direct observed treatment short course (DOTS) has shaped and influenced patient-provider encounters in a district tuberculosis centre (DTC) in a rural district of India.

Qualitative methods, combining observations and interviews, were carried out in a DTC focusing on the medical encounters between a TB doctor and his patients.

The findings showed that the TB doctor seemed to be working with a dilemma, defined as conflicting accountabilities, in the medical encounters. In an organization perceived as inefficient and resource-constrained, the doctor struggled to find a balance between meeting the obligations of the DOTS programme and meeting the needs and expectations of the patients. Strategies to deal with these conflicting accountabilities were identified as limiting patients' involvement, struggling to maintain authority, and transferring responsibility.

Professional involvement and patient participation were seen as part of a linked process in this study, and the importance of empowering doctors and health care workers who are implementing DOTS is emphasized. The development of DOTS guidelines needs to be based on the actual process of health care delivery, and staff empowering efforts should also include strengthening of public health care infrastructure.