Introduction China has an estimated 5 million people with tuberculosis (TB). Official policy is that treatment of all patients is directly observed by health workers; completion rates are reported to be in excess of 90%, and drugs should be supplied for free. However, some research suggests there is a gap between the official policies and practice.

Methods Survey of TB patients in four counties of one municipality; record assessment at one TB centre; patient and village doctor in-depth interviews.

Results Sixteen per cent (64/401) reported being directly observed every time they took treatment; less than 5% of TB patients (17/401) were observed by health staff. Overall, 12.5% (50/401) reported they had not taken any TB drugs in the previous week, but this varied between the four counties (range 6.2 to 21.7%). We used survival analysis with medical records at one centre: 74.1% of new patients collected their drugs for their sixth month of treatment, and 50.3% attended the final visit at 6 months. Qualitative research indicated direct observation is neither well understood nor thought to be necessary, and that patients reported being charged expensive fees for ancillary treatments, such as liver protection drugs.

Conclusion In China, direct observation is not well implemented and may not be a feasible policy option. Official completion rates are higher than we found in this study. The concept of free treatment has become blurred, with charges for additional tests and drugs, especially liver protection drugs. The government is already actively tackling these issues, and involvement of managers and others in this process will be helpful.

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