INT J TUBERC LUNG DIS 15(10):1367–1372
© 2011 The Union
The experience of implementing a ‘TB village’ for
a pastoralist population in Cherrati, Ethiopia
K. Tayler-Smith,* M. Khogali,† K. Keiluhu,† J-P. Jemmy,‡ L. Ayada,‡ T. Weyeyso,§ A. M. Issa,§
G. De Maio,¶ A. D. Harries,#** R. Zachariah*
* Medical Department, Médecins Sans Frontières, Operational Centre Brussels MSF-Luxembourg, Luxembourg;
† Médecins Sans Frontières, Addis Ababa, Ethiopia; ‡ Medical Department, Médecins Sans Frontières, Operational
Centre Brussels, Brussels, Belgium; § Somali Regional Health Bureau, Jijiga, Ethiopia; ¶ Médecins Sans Frontières, Rome,
Italy; # International Union Against Tuberculosis and Lung Disease, Paris, France; ** London School of Hygiene &
Tropical Medicine, London, UK
Correspondence to: R Zachariah, Medical Department (Operational Research), Médecins Sans Frontières, 68 Rue de
Gas perich, L-1617 Luxembourg. Tel: (+352) 332 515. Fax: (+352) 335 133. e-mail: firstname.lastname@example.org
Article submitted 9 December 2010. Final version accepted 18 April 2011.
SETTING: In Cherrati District, Somali Regional State
(SRS), Ethiopia, despite a high burden of tuberculosis
(TB), TB control activities are virtually absent. The ma-
jority of the population is pastoralist with a mobile life-
style. TB care and treatment were offered using a ‘TB
village’ approach that included traditional style residen-
tial care, community empowerment and awareness rais-
ing, provision of essential social amenities and essential
food and non-food items.
OBJECTIVE: To describe 1) key aspects of the implemen-
tation of the TB village approach, 2) TB treatment out-
comes and 3) the lessons learnt during implementation.
DESIGN: Descriptive study.
RESULTS: A total of 297 patients entered the TB village
between September 2006 and October 2008; 271 (91%)
patients were treated successfully, nine (3%) defaulted
and 13 (4%) died.
CONCLUSIONS: For pastoralist populations, a TB vil-
lage approach may be effective for improving access to
TB care, ensuring proper adherence to treatment and
achieving good overall TB outcomes. The successes and
challenges of this approach are discussed.
KEY WORDS: tuberculosis; pastoralists; Ethiopia; TB
ETHIOPIA has one of the highest burdens of tuber-
culosis (TB) in the world,1 with a disproportionately
high burden in the Somali Regional State (SRS) of
Ethiopia. The latter is most probably linked to the re-
gion’s long running history of confl ict,2–5 which has
severely undermined the social sector (people are
consequently extremely poor),6 weakened the health
service infrastructure and led to the virtual absence
of TB control activities.7,8 In addition, most of the
population in the SRS are pastoralists (for the pur-
pose of this study, this term refers to nomads or semi-
nomads raising cattle and other livestock). The popu-
lation is typically mobile, frequently migrating with
their livestock in search of fresh pasture and water.
Conventional TB treatment strategies based on a
fi xed existing health infrastructure are therefore not
adapted to this predominantly mobile group of peo-
ple.9 Finding innovative ways of managing TB in this
population and ensuring treatment adherence is vital
to ensure good patient and programme outcomes.10,11
In 2005, Médecins Sans Frontières (MSF), in col-
laboration with the National TB Control Programme
(NTP), opened a TB project for pastoralists in Cher-
rati, a rural district in the South-East region of the
SRS. A holistic ‘TB village’ approach was used to try
to adapt TB services as much as possible to the client
and social context. In this study, we 1) describe
key aspects of the implementation of the TB village
approach, 2) report on TB treatment outcomes and
3) discuss the successes and challenges (lessons learnt)
in implementing such a model for TB control.
Setting and population
Cherrati is a rural district in the South-East region of
the SRS with a population of approximately 79 000,
consisting mainly of semi-nomadic pastoralists.
MSF, in collaboration with the NTP, initially con-
ducted TB activities through one health centre in
Cherrati town, the district capital. The main target
population at this time was TB patients from nearby
localities. However, over time, a growing number of
patients from distant locations came to seek TB care.
These patients were generally poor and had no means
of supporting their stay in Cherrati while receiving
TB treatment. To overcome this problem, in Septem-
ber 2006, MSF and the NTP decided to pilot a TB
S U M M A R Y
The International Journal of Tuberculosis and Lung Disease
village approach in a locality close to the existing
health centre. The time period was slated for 2 years
(2006–2008), after which the project was handed
over to the NTP. The study analysis thus covers the
period from September 2006 to October 2008. To
cover the other basic health needs of the patients, their
families and those that accompanied them, a pri-
mary health care consultation was also offered in the
Characteristics of the TB village
Patients were suitable for the TB village if they had
no-one to accommodate and support them in Cher-
rati for the duration of their TB treatment. Severely
sick patients who were eligible for the TB village were
hospitalised until they were stable enough to move
into the TB village.
Traditional tukuls (constructed from grass and
sticks) were built to accommodate patients and their
family members (Figure). The TB village was organ-
ised into clusters, with each cluster comprising 50 tu-
kuls, one kitchen area, four to fi ve latrines and one
washing area. In the centre of the village, there was a
communal area (for group meetings) and a waste
area. Any cattle that patients brought with them were
allowed to graze on the land surrounding the village.
During their stay in the village, each patient and
one care giver received free food based on the staple
diet (rice, beans, oil, meat [intermittently], salt and
sugar rations), water and non-food items (such as a
mosquito net, a cooking pot, a blanket). Patients and
their care givers were provided with kitchen areas to
cook for themselves.
To enhance community ownership and empower-
ment, tasks were assigned to patients related to gen-
eral hygiene, security and food distribution. In addi-
tion, a TB village committee, composed of 10–12 TB
patients and their care givers (elected by the TB vil-
lage members), ensured safety and security in the vil-
lage and helped to ensure communal harmony among
patients from different ethnic clans and geographical
locations. With inter-clan problems commonplace in
the SRS, the village committee was empowered to en-
force rules and regulations on harmonious commu-
nal living. Individuals who were not prepared to
abide by these rules were asked to leave the village
and fi nd alternative solutions. Only one patient was
expelled from the village. The overall logistics man-
agement of the village fell under a logistical village
supervisor, employed locally by MSF. TB village
meetings were organised on a monthly basis with TB
patients and their care givers, to discuss issues such
as food distribution, water supply, sanitation, safety
The cost of providing one patient and his/her care
giver with a tukul, food and non-food items for the
entire period of anti-tuberculosis treatment was the
equivalent of respectively US$315 and US$390 for a
6-month and an 8-month TB treatment regimen.
Table 1 illustrates the key considerations, services
and amenities offered in the TB village in Cherrati.
TB diagnosis, treatment and follow-up
TB was diagnosed and managed according to national
guidelines.12 In brief, diagnosis in adults was based
on sputum smear microscopy and clinical examina-
tion by a medical doctor. TB diagnosis in children was
based on the Edwards Score Chart.13 Patients were
Figure Example of the TB village tukuls. This image can be viewed online in colour at http://
Implementing a TB village for pastoralists 1369
further categorised into new and retreatment cases
according to standard practice.12
The different anti-tuberculosis regimens used for
treatment and their indications are shown in Table 2.
During the fi rst 2–3 weeks of the intensive phase of
treatment, patients were directly observed to take each
dose of treatment (supervised swallowing of pills) by
a health care worker. Thereafter, most patients fol-
lowed a self-administered treatment (SAT) approach,
collecting their drugs once weekly or biweekly during
the intensive phase of treatment, and then biweekly
during the continuation phase. Patients deemed to be
at risk of poor treatment adherence by the manage-
ment team continued on directly observed treatment
(DOT) for as long as was considered necessary. Pa-
tients were followed up clinically every 2 weeks dur-
ing the intensive phase of treatment and once monthly
during the continuation phase of treatment.
Patients received two fi xed individual counselling
sessions, one prior to beginning treatment and one
when changing from the intensive to the continuation
phase of treatment, together with counselling sessions
each time they collected their drugs.
Data collection and statistical analysis
Data from patient treatment cards and the TB regis-
ters were cross-checked. The following data were col-
lected and entered into an Excel database (Microsoft,
Redmond, WA, USA): date of registration, age, sex,
treatment regimen, treatment outcome and date of
outcome. TB treatment outcomes for all patients were
the primary outcome measure of interest, as based
on the standard national12 and World Health Organi-
zation defi nitions.14 The χ2 test was used to compare
groups where relevant. The level of signifi cance was
set at P ⩽ 0.05. Data were analysed using STATA/IC
8.0 software (Stata Corp, College Station, TX, USA).
Formal approval for this study was obtained from
the Somali Regional Health Bureau in Ethiopia,
t ogether with ethics approval from the MSF ethical
review board and the Ethics Advisory Group of the
International Union Against Tuberculosis and Lung
Disease. Data in this study did not include any patient-
Characteristics of the study population
Between September 2006 and October 2008, a total
of 340 TB patients were admitted into the TB village
in Cherrati. A total of 43 (11%) patients had un-
known TB outcomes and were excluded from the
study. Close to half of these unknown outcomes re-
late to a period of instability and confl ict in the re-
gion and we believe that patient cards were misplaced
Of the 297 patients included in the analysis, there
were 134 (45%) women. Over half (n = 161, 54%)
had smear-positive pulmonary TB (PTB), 49 (17%)
smear-negative PTB and 55 (19%) extra-pulmonary
TB. Table 3 shows the baseline characteristics of the
Table 1 Key considerations, services and amenities offered
in a TB village for pastoralists in Cheratti, Ethiopia
• Offer a model of TB care to a population that is predominantly
mobile and migrant within a framework of very limited/
non-existent health infrastructure
• Offer care that is patient centred and adapted to the cultural
and social context
• Build a residential setting for patients that mirrors as far as
possible a traditional lifestyle and way of living
• Enhance community empowerment, ownership, responsibility
and solidarity in TB management and care
• Have a strong component of community awareness and
dissemination of information on TB, including the importance
of treatment and treatment adherence
• Mobilise infl uential community members (e.g., religious leaders,
clan leaders) to impart this knowledge to the wider community
• Deploy strategies (e.g., fi nancial incentives) to encourage
the retention and recruitment of health care staff in a
Services and amenities offered
• Individual household shelters (tukuls) built in the traditional
• Free food rations based on the staple diet (rice, beans, oil, salt
and sugar) and cooking facilities, allowing patients and care
givers to cook food according to their taste and culture
• Free non-food items (soap, mat, jerry can, blanket, bed-net,
kerosene lamp, cooking utensils)
• Free water and containers for patients and care givers (minimum
• Sanitation (latrines) and waste disposal facilities
• Communal area for group meetings and gatherings
• Land outside the perimeter of the village for cattle to graze on
• Security for patients and those accompanying them
• A community committee that could be contracted to raise issues
of concern regarding patient and community welfare
• A village logistic supervisor to maintain the upkeep of the village
Table 2 TB regimens and indications
8-month regimen2RHZE/6EHAdults with new
PTB and new EPTB
Adults with new
PTB and new EPTB
Retreatment of any
form of TB
TB meningitis in adults
TB meningitis in adults
Children with any
form of new TB
Paediatric regimen 1
* A regimen consists of two phases: the intensive and the continuation
phase. The number before a phase is the duration of that phase in months.
† The 6-month regimen replaced the 8-month regimen in July 2007.
TB = tuberculosis; R = rifampicin; H = isoniazid; Z = pyrazinamide; E =
ethambutol; PTB = pulmonary tuberculosis; EPTB = extra-pulmonary tuber-
culosis; S = streptomycin.
The International Journal of Tuberculosis and Lung Disease
TB treatment outcomes
Table 4 shows standardised TB treatment outcomes
by TB type, category and regimen. The overall treat-
ment success rate was 91%, while the default and
death rates were respectively 3% and 4%. Even when
patients with unknown outcomes (n = 43) were in-
cluded in the analysis, the treatment success rate was
80%. Treatment outcomes did not differ signifi cantly
between the 8-month and the 6-month regimens (data
This experience shows that for a pastoralist popula-
tion in Ethiopia, a TB village approach to TB care de-
livery is associated with very high treatment success
and low adverse (defaulter and deaths) outcomes.
We believe that the success of the TB village ap-
proach in Cherrati is underpinned by a number of
factors. First, anecdotal evidence suggests that the
most attractive component of the TB village approach
to patients (and the main reason for the very low de-
faulter rate) was the offer of free housing coupled
with free food and other amenities. A previous study
in Ethiopia found that poor physical access to health
care services was one of the main reasons for low TB
treatment adherence, and this hurdle for patients was
overcome through the TB village approach.15 Further-
more, the offer of free food in a context where food
insecurity is a problem provided a strong incentive
for patients to remain in one place for the entire du-
ration of their treatment.16 Interestingly, after treat-
ment completion, we did not face any problems send-
ing patients away.
Second, we embarked on community awareness ac-
tivities, targeting and mobilising infl uential commu-
nity members (religious leaders, clan elders and tradi-
tional healers) to impart knowledge about TB and its
treatment to the wider community. With no active
case-fi nding systems present in the SRS, and no health
infrastructure to rely on, we believe that the large
number of patients who came from distant locations
(sometimes more than 100 km away) to seek TB care
in Cherrati was due to the extensive TB awareness
raising activities undertaken by MSF at the beginning
of the project. These activities also likely contributed
to the high treatment success and low defaulter rates.
Other studies have shown that limited community
TB awareness negatively impacts on health-seeking
Third, we were fl exible in using a treatment strat-
egy comprised of 2–3 weeks of DOT during the
Table 3 Baseline characteristics of TB village patients
TB = tuberculosis; IQR = interquartile range; PTB = pulmonary tuberculosis;
EPTB = extra-pulmonary tuberculosis.
Table 4 TB treatment outcomes for pastoralists in Cherrati, Ethiopia (n = 297)
Lost to follow-up
All TB patients
New TB case
Short-course (6 months)
Short-course (8 months)
271 (91.3)13 (4.4) 9 (3.0) 1 (0.3)3 (1.0)
* Includes both patients who were cured and those who completed TB treatment.
† Includes any patient who received at least 1 month of TB treatment in the 5 past years and returns with a diagnosis of TB.
‡ There were no cases of return after default and no failures.
TB = tuberculosis; PTB = pulmonary tuberculosis; EPTB = extra-pulmonary tuberculosis.
Implementing a TB village for pastoralists 1371
i ntensive phase of treatment, followed by a SAT ap-
proach. In a setting with only one health centre and
limited human resources, the SAT approach freed up
time for the limited number of health care staff, al-
lowing them to manage larger TB case loads and ad-
ditional non-TB-related health care activities.
Fourth, we adapted living conditions as much as
feasible to the patients’ traditional lifestyle as a means
of encouraging them to stay in the TB village for the
entire duration of treatment. We believe this contrib-
uted to the low defaulter rate and allowed effective
monitoring of outcomes. The concept of a TB village
was fi rst developed and implemented in Kenya in
1987 through the Manyatta Project, which provided
TB care and treatment for Kenyan nomads.19 Unlike
our model of care delivery, however, the Manyatta
Project provided patients with food and housing only
during the intensive phase of treatment, after which
patients were discharged from the village to continue
a 3-month regimen unsupervised. Among 996 new
smear-positive patients treated in two nomadic dis-
tricts in Kenya, the treatment success rate was 78%
and loss to follow-up 21%. The relatively high loss to
follow-up using this approach, compared with that
observed here, refl ects the fact that a substantial pro-
portion of patients never returned for follow-up at
the end of treatment and were declared defaulters.
There were a number of challenges associated with
running the TB village and the TB project as a whole.
First, with the highly attractive offer of free food for
6–8 months, there were reported incidents of ‘non-
TB’ patients bribing staff to be admitted into the vil-
lage. Second, in a remote context such as Cherrati, re-
cruiting and retaining health care workers proved a
major challenge. MSF was able to address this prob-
lem to some extent by offering staff higher salaries.
Third, with the SRS a confl ict-prone area, there were
the usual challenges of feasibility and sustainability
of interventions, as well as programme quality.16 Dur-
ing confl ict periods, MSF expatriate staff were often
evacuated and general standards of supervision and
management fell in their absence. This highlights the
importance of increased emphasis on national staff
The major challenge of implementing a TB vil-
lage approach nationally in a resource-poor setting
such as Ethiopia is the economic implications. In
Cherrati, the cost of providing each TB patient with a
tukul, food and non-food items alone for the dura-
tion of their TB treatment was nearly US$400. While it
has not been possible to conduct a cost-effectiveness
analysis of the TB village approach in this paper,
these costs need to be weighed against a number of
operational considerations: 1) the burden of TB is
high among pastoralist communities and interventions
to address this are urgently needed; implementing TB
treatment is made ever more challenging by the fact
that pastoralist communities often dwell in highly
volatile and insecure environments; 2) the health in-
frastructure is seriously dilapidated, and TB control
activities are often absent;7,8,20 3) as health care is not
decentralised, geographic access is diffi cult; and 4) fi -
nancial and human resources are severely limited.
The overall cost of US$400 should thus be balanced
against the usual alternative model, which would
have involved the costs and time required to build
new TB centres, in-patient wards, provide decen-
tralised transport for supervision teams, etc., which
are likely to cost substantially more and would not
necessarily ensure high treatment adherence or sus-
tainability. Although we also provided primary care
consultations in addition to TB care, it would be
worthwhile to consider how a ‘platform’ like the TB
village could be used to address certain other health
care needs of the population. Such additions would
further increase the cost-effectiveness of TB villages.
The ideal would be for national health authorities to
run and fund such initiatives. Given that TB control
is a global priority and essential to achieving the Mil-
lennium Development Goal (MDG) targets, donor
funding for such adapted initiatives seems justifi ed as
one manner of approaching the TB burden in specifi c
In settings such as the SRS, other community-based
strategies to tackle the high burden of TB among pas-
toralist populations should also be considered and
may be cost-effective.20,21 The implementation of ‘TB
clubs’ and the involvement of traditional healers, for
example, have been shown to signifi cantly improve
Finally, a better understanding of the migratory
patterns of pastoralist communities may allow for the
more strategic placement of health care services to
improve access for these communities. The migration
patterns of pastoralists vary from a stable migra-
tion, where migration takes place between two well-
defi ned grazing areas, to unpredictable migration,
guided by the availability of water and pasture.8,28
Previous studies have suggested that the migration
routes of pastoralists in the SRS are predictable.20,28
If this is indeed the case, temporary outreach TB man-
agement facilities could be established in strategic vil-
lages so that pastoralists are able to access these facil-
ities in both the dry and wet seasons.
In an era where TB control is an international pri-
ority, TB control among pastoral communities re-
mains a relatively neglected issue in the Horn of Af-
rica, with many pastoralists still struggling to access
TB care29 due to their mobile lifestyle.9 A TB village
approach may be an effective way of fi lling the gap of
access to TB care while also ensuring good overall TB
This study was funded by the Médecins Sans Frontières Brussels
The International Journal of Tuberculosis and Lung Disease
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Implementing a TB village for pastoralists i Download full-text
CONTEXTE : Dans le district de Cherrati, État régional
Somali (SRS), Ethiopie, en dépit d’un fardeau élevé de
tuberculose (TB), les activités de lutte antituberculeuse
sont virtuellement absentes. La majorité de la popula-
tion est constituée d’éleveurs de bétail nomades. Les
soins et le traitement de la TB leur ont été offerts en utili-
sant une approche « TB village » qui comportait des
soins résidentiels de style traditionnel, la responsabilisa-
tion de la collectivité, l’augmentation de la prise de con-
science, la fourniture des ressources sociales essentielles
et des items essentiels nutritionnels ou non.
OBJECTIF : Décrire 1) des aspects de la mise en œuvre
de l’approche TB village, 2) des résultats du traitement
de la TB et 3) des leçons tirées au cours de la mise en
SCHÉMA : Etude descriptive.
RÉSULTATS : Entre septembre 2006 et octobre 2008,
297 patients sont entrés dans le programme TB village ;
271 (91%) ont été traités avec succès, neuf (3%) ont
abandonné et 13 (4%) sont décédés.
CONCLUSION : Pour les populations pastorales, une ap-
proche TB village peut être effi ciente pour l’amé lioration
de l’accès aux soins TB, pour garantir une bonne adhé-
sion thérapeutique et obtenir des résultats globaux favo-
rables dans la TB. Les succès et défi s de cette approche
MARCO DE REFERENCIA: En el distrito de Cherrati, en
el Estado Regional Somalí en Etiopía, donde pese a una
alta carga de morbilidad por tuberculosis (TB) y prácti-
camente no existen medidas de control de la TB. La
mayoría de la población está compuesta por pastores
con un modo de vida nómada. Se ofrecieron servicios de
atención y tratamiento de la TB con una estrategia de
‘aldea de atención de la TB’ (TB village) en la cual se
prestaba la atención residencial tradicional, la capacita-
ción y la habilitación de la comunidad, la sensibiliza-
ción, la provisión de servicios sociales básicos y el sumi-
nistro de alimentos y otros artículos esenciales.
OBJETIVOS: 1) Describir los aspectos fundamentales de
la introducción de la estrategia TB village, 2) evaluar los
desenlaces terapéuticos y 3) analizar las enseñanzas ex-
traídas durante la puesta en práctica de la estrategia.
MÉTODO: Fue este un estudio descriptivo.
RESULTADOS: Entre septiembre del 2006 y octubre del
2008 ingresaron a la aldea de tratamiento de la TB
297 pacientes. Se logró el tratamiento exitoso de 271
(91%) pacientes, se presentaron nueve abandonos (3%)
y 13 pacientes fallecieron (4%).
CONCLUSIÓN: La estrategia TB village puede consti-
tuir un enfoque efi caz en las poblaciones pastoriles, con
el fi n de mejorar el acceso a la atención de la TB, lograr
un buen cumplimiento terapéutico y alcanzar desenlaces
clínicos globales adecuados. En el artículo se analizan
los éxitos y las difi cultades de esta estrategia.
R É S U M É
R E S U M E N