Case Synopsis

Paru Hari, an Accredited Social Health Activist (ASHA), lives in Bihar, India, one of the poorest states in the country. Paru is involved in daily outreach within her community to facilitate community member access to health care facilities, administer medications, treat minor ailments, and generate health awareness. The majority of her work involves antenatal checkups, immunizations, and mild sickness treatments. However, with Bihar reporting approximately 70,000 new cases of tuberculosis (TB) annually and many cases going unreported and undiagnosed (Fathima, Varadharajan, Krishnamurthy, Ananthkumar & Mony, 2015; RESULTS Canada, 2018b), Paru decided to take action. She proposed that ASHAs act as TB educators and household screeners for patients who have TB because she was tired of watching people in her community suffer and die from a treatable disease. Paru decided to visit Dr. Tisha Guru, Bihar state’s Regional ASHA Program Director, to share her concerns about how best to integrate TB educational activities and household screening programs into her daily routine. For Paru to gain a clear understanding of what she needs to know to identify TB patients and what they require during diagnosis and treatment, Dr. Guru suggested that she accompany patients from the initial stages of their diagnosis through to treatment. Although Paru did not have an extensive medical background, she knew that the ASHA program required a great deal of funding to ensure it was sustainable and that the necessary resources were available for TB testing and care to be integrated into their daily work. Paru knew action needed to be taken, not only to continue the ASHA program but, more importantly, to help patients who were being overlooked by the current health care system. Paru worked alongside Dr. Guru to identify the key stakeholders who could effectively communicate the critical need for improved TB surveillance, educational activities, and household screening programs into the services ASHAs provided.

Case Objectives

1. Describe the challenges in developing effective programs in terms of health care and health equity in India.

2. Understand and explain the impact that social determinants of health have on people who have TB, and the role these determinants have in disease development.

3. Propose strategies to identify and engage stakeholders and build partnerships for influencing public health outcomes.

4. Identify culturally appropriate public health content for TB educational programs that can be distributed, both in written and verbal form, to the marginalized populations of Bihar.

5. Formulate an effective response that includes community level approaches and culturally and context-relevant strategies to improve population health for the marginalized populations of Bihar, India who are facing high rates of undiagnosed and unreported TB cases.

Case Study Questions

1. What is the main problem or issue discussed in the case?

2. Who are the key players in the case and what are their roles?
a. Do you feel that the ASHA program is appropriate for increasing the TB case-finding rate?
b. Do you have any other ideas or strategies for creating sustainable programs that would be effective in this scenario?

3. What are the differences between the social and structural determinants of TB?

4. How could Dr. Guru and Paru create a comprehensive and culturally appropriate training manual that can benefit all ASHAs working in the villages of Bihar?
a. Do you think creating such a manual is possible? Why or why not?

5. How could Dr. Guru and Paru ensure sufficient monitoring and surveillance of the manual’s success?
a. Can you think of any techniques, strategies, theories, or frameworks they could use?

6. What methods could Dr. Guru and Paru use to assess the effectiveness of the training?
a. Would you use quantitative or qualitative data collection methods, or are both appropriate?

7. How would Dr. Guru and Paru cover the costs needed for program development and implementation?

8. Which stakeholders need to be engaged to ensure the training is effective and implemented at the community level?


ASHAs; case-finding rate; health equity; social determinants of health; TB burden; tuberculosis

Additional Author Information

Ashley Fantauzzi, BASc, Pg. Certificate, GBM, MPH

Taryn Russell, Campaigns Director

Shannon L. Sibbald, PhD, Assistant Professor



Recommended Citation

Fantauzzi, A., Russell, T. & Sibbald, S.L. (2019). The Missing Four Million: Working to Increase the Case Finding Rate for People with TB. In: Sibbald, S.L. & McKinley, G. [eds] Western Public Health Casebook 2019. London, ON: Public Health Casebook Publishing.