Negotiating Tuberculosis in Pakistan: Social Capital Analysis of Barriers and Resources

Abstract

“Negotiating Tuberculosis” is the outcome of sixteen months field work which examines existing barriers and available resources for reaching TB centers of Murree Punjab, Pakistan. During this study, I engaged staff from National and Provincial Tuberculosis Control Programmes, local healthcare structure besides formal and informal biomedical providers and TB patients to know that how the initiatives of TB control program interacts with social life in Murree within the concept of social capital, political economy of health, geography and environment. The major argument of this study is that how global TB policies are being implemented through a local healthcare structure that is fragmented in various indicators. This research was conducted in two phases. The first phase was to interact with TB patients in OPD of Samli Hospital where convenient sampling was used and 93 TB patients showed their willingness to become part of study. Multi-dimensional Poverty Index and social capital measurement tools were applied to measure the level of deprivation and social capital. For the second phase, a sample of 20 TB patients was selected through judgmental sampling for in-depth study through life history method. Qualitative methods such as participant observation, informal discussions, key informants interviews, FGDs and in-depth interviews were conducted to understand the research problem. Overall, healthcare structure of Murree had not enough human resources and facilities to develop the trust of people for initial screening of TB. The overburdening of government hospitals was the result of political economy of health through which local healthcare structure was not developed. The unclear population growth had failed to implement global TB control programme through a broken healthcare structure. In such a situation, social capital is the only tool to get easy access to doctor and TB diagnostic facility but it is not the property of poor segments of Murree. The utilization of social capital had resulted in inequalities and placed barriers for the poor to get equal access to available health facilities to cure their TB. A fargile doctor-patient relationship was based in various forms of powers exhibition and it had turned into low level of trust among the poor segments who had no financial capacity to visit doctors on their private clinics regularly. This power-based relationship was one of the barriers for visiting government healthcare facilities. The IV political economy of health gained attention of doctors towards private practice and the poor had more trust in a quack. This situation turned into health risk for the poor and marginalized segments of Murree. The poverty and political economy were the major barriers to develop social capital among the poor and due to their low level of social capital, they could not find equal access to distribution of social goods and services. There is always a contextual background for the development of health seeking behavior. Long standing poverty, political economy, geography, environment and least trust in government healthcare facility developed a low health seeking/prioritizing behavior among the poor segments of Murree due to which they initiated from household remedies to cure every disease. This behavior was the cause of following different pathways for finally reaching a government TB center that remained a barrier for timely TB diagnosis.