Local adaptation versus standardization? Treatment delivery for multi-drug resistant Tuberculosis in India

Treatment of Tuberculosis (TB) and multi-drug resistant Tuberculosis (MDR-TB) is a public good, due to the risk of transmission of infectious strains and the potential amplification of drug-resistance. The provision of this public good by government programmes has to bear a tension between standardized guidelines within programmatic constraints and local adaptation responding to needs for individual care. This tension is central to Tuberculosis control and is rendered more urgent for the prolonged and complicated MDR-TB treatment. This paper focuses on the first treatment sites for MDR-TB of the public TB programme in India. My fieldwork shows that actors here struggle with the interplay between local adaptation and standardization in service delivery. The literature casts this relationship often in terms of ideological opposites and thus actors would have to make normative choices for one over the other. My results show that there is indeed a risk of being caught in dilemma-thinking, namely that local adaptation goes at the expense of control through standardization and vice versa. Yet, the dilemma-thinking prevents a content-related discussion on the different forms of local adaptation and standardization which actors engage in. Their practices and understandings demonstrate that the relation between local adaptation and standardization can be better characterized in terms of effectiveness; with the actors defining effectiveness differently. To avoid seemingly opposite ethical stands, favouring standardization or local adaptation, it is helpful to analyse different practices engaged with standardization and local adaptation, and to understand how actors relate to them.