Criticl evlution of the Globl DOTS Expnsion Pln Donld A Enrson & Nils E Billo Abstrct The development of the DOTS Expnsion Pln hs been milestone in tuberculosis (TB) control t the globl nd ntionl levels. Key chllenges tht remin re overcoming the wekness of strtegy built on cse mngement, sustining commitment, competing priorities, the thret of HIV, mintining high qulity of cre nd preventing drug resistnce, building humn resource cpcity, improving dignosis nd fostering opertions reserch. The bility to ddress these chllenges will determine the success or filure of the Globl Pln to Stop TB, 2006 2015. Bulletin of the World Helth Orgniztion 2007;85:395-403. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. espñol. Une trduction en frnçis de ce résumé figure à l fin de l rticle. Al finl del rtículo se fcilit un trducción l Introduction The recent Globl Pln to Stop TB, 2006 2015 1 tkes into ccount the chllenges identified during the five yers of the Globl DOTS Expnsion Pln (GDEP), which rn from 2001 to 2005. At workshop in Ciro in November 2000, ntionl TB progrmme (NTP) mngers from the 22 high-burden countries, WHO, technicl prtners, development gencies nd donors greed to develop the GDEP in response to the Amsterdm Declrtion nd resolution of the World Helth Assembly (WHA) in My 2000. 2 The focus of the GDEP would be to estblish ntionl DOTS expnsion plns nd develop prtnerships to control TB. Prticipnts t the workshop identified nine key res of work s criticl to chieving the gols of the Amsterdm Declrtion nd the WHA resolution development of five-yer plns, incresed politicl commitment, enhnced ntionl nd interntionl prtnerships, socil mobiliztion, humn resource development, improved TB drug procurement, qulity ssurnce of smer exmintion nd opertionl reserch to improve TB control. Mjor progress hs been mde since tht time, including: 3 vibrnt interntionl Stop TB prtnership; severl progrmmes with ntionl TB prtnerships; ntionl DOTS expnsion plns in ll high-burden countries; the Globl TB Drug fcility (GDF); sustined interest of interntionl policy-mkers; mobiliztion of substntil finncil resources through estblished mechnisms (e.g. development gencies) nd new mechnisms (e.g. the Globl Fund for AIDS, TB nd Mlri); commitment of ntionl public uthorities to doption nd dpttion of interntionl policies; implementtion of cse mngement in routine helth services; nd incresed support for development of new dignostics, drugs nd vccines. However, key chllenges remin nd my not hve been sufficiently ddressed in the GDEP. This pper discusses these chllenges. Wekness of the core strtegy Prevention bsed on cse mngement hs never eliminted or erdicted ny disese only vccine-bsed strtegies hve chieved this. 4 Situting prevention in cse mngement (i.e. in routine helth services) mens tht ll the chllenges of estblishing nd mintining qulity helth services (e.g. ccess, equity nd competing priorities) must be fced. The focus on downstrem interventions prioritizes cse mngement nd even the ppliction of the currently vilble vccine (which prevents serious forms of disese in smll children but hs not been demonstrted to prevent primry infection). 5 This pproch fils to ddress fctors relted to poverty, with which TB is intimtely ssocited. Sustining ownership nd empowerment In fighting TB, economic rguments hve been used to engge key stkeholders. These rguments re bsed on the reltive cost-effectiveness of the interventions nd the economic gins to be mde from following the strtegy. For exmple, the World Bnk promoted the view tht governments could not fford not to implement DOTS. 6 Although this pproch hs been successful in certin loctions, bilterl nd multilterl gencies hve sometimes undermined the economic rgument by shifting responsibility for budgets for TB control from ntionl to interntionl sources. 7,8 Ownership of the domin hs consequently been tken up by interested prties t n interntionl level, rther thn by those primrily ffected. This sitution tends to disempower locl nd ntionl stkeholders. Addressing competing interests nd fshions Helth services worldwide hve limits on their resources, prticulrly where resources re scrce. Also, resources re not lwys llocted ccording to evidence, especilly in poor nd mrginlized communities. 9 Rther, they re often subject to specil interests nd fshions in the re of interntionl development policy, with the only stble fctor in such policy being the desire to chnge it. The exmple of WHO reflects this tendency. When formed, the orgniztion Interntionl Union Aginst Tuberculosis nd Lung Disese, 68 boulevrd Sint-Michel, 75006 Pris, Frnce. Correspondence to Nils E Billo (e-mil: nbillo@iutld.org). doi: 10.2471/BLT.06.035378 (Submitted: 24 October 2006 Finl revised version received: 19 Februry 2007 Accepted: 22 Februry 2007) Bulletin of the World Helth Orgniztion My 2007, 85 (5) 395
Criticl evlution of the Globl DOTS Expnsion Pln Donld A Enrson & Nils E Billo included specilized TB unit. 10 Efforts in TB control coincided with stedy declines in TB mortlity nd morbidity in industrilized countries. 11 However, similr progress ws not observed in low-income countries, nd the pproch ws hevily criticized. 12 A subsequent shift of emphsis from specilized to generlized primry cre services followed the doption of the slogn Helth for ll by the yer 2000. 13 As the yer 2000 pproched, however, this slogn disppered, nd trgeted pproches (to TB, mlri, tobcco nd other specific issues) emerged nd gined high visibility. If fshions chnge, will it be possible to provide the decdes of commitment required to chieve the GDEP s gols? Stemming the tide of HIV In some countries, prticulrly in southern sub-shrn Afric, TB nd HIV re closely linked; for exmple, in the highest-burden settings, 75% of TB ptients re lso living with HIV/AIDS. 14 Due to the link between TB nd HIV, sub- Shrn Afric is likely to supersede ll other regions in the burden of TB over the coming decdes. 15 The trend of rising TB cse rtes cn only be reduced if HIV infection rtes re lso reduced. The Stop TB Prtnership (the orgniztion tht developed the GDEP) nd its TB/HIV working group recognize this sitution, but not ll current pproches ddress the chllenge. Filure to link efforts in TB control to those imed t reducing HIV infection rtes will undermine ll other efforts to stop TB. Mny countries hve ttempted to improve collbortion between TB nd HIV services, but progress hs been pinfully slow nd indequte. 16 Mintining service qulity, preventing drug resistnce The qulity of cre for TB ptients is inextricbly linked to the future of the TB epidemic. 12 By keeping ptients live but filing to cure them, poor tretment ctully ugments the spred of TB. Also, high proportion of previously treted cses hrbour drug-resistnt bcilli nd trnsmit infection in the community. 17,18 Recently, there hve been outbreks of extensively drug-resistnt (XDR) TB, even in loctions tht hve supposedly dopted interntionl recommendtions for stndrd cse mngement. 19 Access to second-line medictions nd improper use of these medictions hs not prevented, nd my even hve promoted, these outbreks. It is uncler how much the rther strict conditions of the DOTS strtegy cn be liberlized without dverse consequences. Wht is cler is tht, in loctions where the rther old-fshioned strict policies hve been conscientiously followed (e.g. United Republic of Tnzni, 20 Benin 21 nd Nicrgu 22 ), the numbers of multidrug resistnt (MDR) cses re low; wheres, in situtions where only some elements of the strtegy hve been strictly dopted, MDR- 23 nd XDR-TB 19 hve emerged. These finding suggest tht strict policies re crucil in preventing emergence of drug resistnce. Such considertions hve prticulr relevnce where stndrd cse mngement is provided in multiple sectors, prticulrly the privte sector, where qulity of services repetedly hs been shown to be deficient. 24,25 Cn the qulity of such services be improved? And if so, cn improved qulity be sustined? In other conditions (e.g. sthm), stndrd cse mngement (i.e. cre bsed on guidelines) hs been demonstrted to be the mngement of choice (i.e. the best stndrd of cre), but lthough professionl bodies nd specilists subscribe to the theory, they rrely crry it out in prctice. 26 Efforts to improve qulity of cre within the privte sector hve been initited within WHO s Stop TB Deprtment; for exmple, through the publiction of the Interntionl Stndrds for Tuberculosis Cre. 27 Also, some studies suggest tht qulity of cre cn be improved through trgeted interventions to encourge prtnership. 28,29 Ensuring the consistent delivery of high-qulity of cre t ll levels of the helth service nd within ll sectors will be key chllenge. If the GDEP pln (or the more recent Globl Pln to Stop TB) hs not sufficiently ddressed this point, it will be mjor chllenge to the strtegy. Ensuring sufficient humn resource cpcity The GDEP succeeded in mobilizing dditionl resources from vriety of sources, nd mny countries hve been ble to expnd DOTS ccording to their 5-yer plns, often creting intergency committees to improve coordintion between the vrious stkeholders. Improving coordintion, voiding dupliction of efforts nd voiding giving conflicting recommendtions will continue to be chllenge for ll prtners. Tody, NTP mngers spend much of their time writing funding proposls, prepring reports (in different formts for ech donor) nd orgnizing review visits for their multitude of prtners. NTP mngers nd progrmme stff need to hve enough time for ctivities criticl to improving TB control. The Ciro workshop identified the need to increse politicl commitment to secure dequte humn resources nd finnces for ll TB control components t ntionl nd sub-ntionl levels. 30 Substntil funding hs been obtined from mny donors in prticulr from the Globl Fund. 31 However, mny countries still find it difficult to implement effective humn resource development strtegies nd to secure sufficient funding for this purpose. 32 Although trining courses re offered t ntionl nd interntionl levels, countries re struggling to retin qulified personnel. For exmple, qulified nd well-trined stff often seek employment in the privte sector or in interntionl bodies, or migrte to industrilized countries. 33 Provision of dditionl funding cn overwhelm some countries, prticulrly where bsorption cpcity is hmpered by indequte mngement systems. 34 Thus, reinforcement nd mintennce of humn resource cpcity in technicl nd mngement domins probbly represents the min chllenge for TB control in the next decde. Assuring qulity of dignosis Estblishment nd implementtion of qulity ssurnce for dignostic exmintion (sputum-smer microscopy) ws one of the GDEP s min gols. This bsic test, which should be techniclly fesible t ny loction, is fundmentl to TB dignostic service. Gret progress hs been mde in estblishing globl consensus on methods for qulity ssurnce of sputum-smer microscopy, 35 nd group of experts hs been set up to develop improved tools nd strtegies for dignostic services. 36 In spite of these dvnces, the qulity of sputum-smer exmintion remins deficient in mny (if not most) sites, nd recommended progrmmes for qulity ssurnce hve not been widely implemented. 37 Current dignostic procedures remin cumbersome nd time-consuming. 396 Bulletin of the World Helth Orgniztion My 2007, 85 (5)
Donld A Enrson & Nils E Billo Specil theme Tuberculosis control Criticl evlution of the Globl DOTS Expnsion Pln Confirming dignosis by definitively demonstrting the presence of Mycobcterium tuberculosis continues to tke dys or weeks, nd even sputum-smer microscopy my necessitte visits to helth fcilities over severl dys. The need for, nd benefits of, new technology tht cn provide on-the-spot, relible dignostic tools re obvious. Mintining criticl spirit A climte of criticl reflection is necessry for effective nd efficient public helth. 38 This cn be chieved through n imbedded progrmme of opertions reserch (nother plnk of the GDEP nd importnt in the first formultion of the NTP s idel structure). 39 Although studies from limited number of loctions hve been published over the pst decde, 40 42 the estblishment nd mintennce of opertions reserch is rrely routine ctivity within NTPs. Implementtion of routine stndrdized monitoring of dignosis nd tretment outcomes using cohort nlysis hs helped to improve NTPs qulity of services, 43 nd hs provided vluble informtion for opertionl plnning nd mngement. Clerly, the GDEP nd the Globl Pln to Stop TB hve mde gret strides towrds reducing the huge burden to helth cused by TB, but much more remins to be done if we re to overcome the chllenges discussed here. O Competing interests: None declred. Résumé Evlution critique du pln mondil d élrgissement de l strtégie DOTS Le développement du pln d élrgissement de l strtégie liée u VIH, le mintien de l qulité des soins, l prévention DOTS constitué une étpe importnte dns l lutte contre l de l phrmcorésistnce, l constitution de cpcités dns le tuberculose (TB) à l échelle tnt ntionle que mondile. Les domine des ressources humines, l méliortion du dignostic principles difficultés à surmonter restent : l fiblesse d une et l encourgement de l recherche opértionnelle. L cpcité strtégie reposnt sur l prise en chrge des cs, l durbilité des à fire fce à ces difficultés est déterminnte pour le succès ou enggements, l concurrence entre les diverses priorités, l mence l échec du Pln «Mondil Hlte à l tuberculose» 2006-2015. Resumen Evlución crític del Pln Mundil de Expnsión del DOTS L formulción del Pln de DOTS h sido un hito de l luch prevención de l frmcorresistenci, l creción de cpcidd de ntituberculos nivel mundil y ncionl. Entre los grndes recursos humnos, l mejor del dignóstico y el fomento de ls retos que ún hbrá que superr cbe citr l debilidd de un investigciones opertivs. L cpcidd de frontr esos desfíos estrtegi bsd en el mnejo de los csos, el mntenimiento determinrá el éxito o el frcso del Pln Mundil pr Detener del compromiso, l competenci de otrs prioriddes, l menz l Tuberculosis 2006 2015. del VIH, el mntenimiento de l lt clidd de l tención y l ملخص تقييم ناقد للخطة العاملية لتوسيع استراتيجية املعالجة القصرية األمد تحت اإلرشاف املبارش ت ع د الخطة العاملية لتوسيع استراتيجية املعالجة القصرية األمد تحت اإلرشاف املبارش من املالمح البارزة ملكافحة السل عىل الصعيد اإلقليمي والوطني. إال أن هناك تحد يات التزال ماثلة أمامها وهي الضعف الغالب عىل االستراتيجية يف كل من معالجة الحاالت وضامن استمرار االلتزام واألولويات املتنافسة وتهديدات اإليدز والعدوى بفريوسه واملحافظة عىل الجودة الرفيعة يف إيتاء الرعاية وات قاء ظهور املقاومة لألدوية وبناء قدرات املوارد البرشية وتحسني التشخيص وتفعيل البحوث امليدانية. إن القدرة عىل مواجهة هذه التحد يات هي التي ستحد د نجاح أو فشل الخطة العاملية لدحر السل 2015.2006 1. 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Donor funding priorities for communicble disese control in the developing world. Helth Policy Pln 2006; 21: 411-420, Epub 2006 Sep 18. 10. Rviglione MC, Pio A. Evolution of WHO policies for tuberculosis control, 1948-2001. Lncet 2002;359:775-80. 11. Styblo K, Meijer J, Sutherlnd I. The trnsmission of tubercle bcilli. Its trend in humn popultion. KNCV Selected Ppers 1971;13:1-104. 12. Grzybowski S, Enrson DA. The fte of cses of pulmonry tuberculosis under vrious tretment progrms. Bull Int Union Tuberc 1978;53:70-5. 13. Brown TM, Cueto M, Fee E. The World Helth Orgniztion nd the trnsition from interntionl to globl public helth. Am J Public Helth 2006; 96:62-72. Bulletin of the World Helth Orgniztion My 2007, 85 (5) 397
Criticl evlution of the Globl DOTS Expnsion Pln 14. Corbett EL, Mrson B, Churchyrd GJ, De Cock KM. Tuberculosis in sub-shrn Afric: opportunities, chllenges, nd chnge in the er of ntiretrovirl therpy. Lncet 2006;367:926-37. 15. Schulzer M, Fitzgerld JM, Enrson DA, Grzybowski S. An estimte of the future size of the tuberculosis problem in sub-shrn Afric resulting from HIV infection. Tuber Lung Dis 1992;73:52-8. 16. Dye C, Wtt CJ, Bleed DM, Hosseini SM, Rviglione MC. Evolution of tuberculosis control nd prospects for reducing tuberculosis incidence, prevlence, nd deths globlly. JAMA 2005;293:2767-75. 17. Schulzer M, Enrson DA, Grzybowski S, Hong YP, Kim SJ, Lin TP. An nlysis of tuberculosis dt in Tiwn nd Kore. Int J Epidemiol 1987;16:584-9. 18. Knvki S, Mntdkis E, Nikolou S, Ppvssiliou A, Krmbel S, Angnostou S, et l. Resistnce of M. tuberculosis isoltes from different popultions in Greece, 1993-2002. Int J Tuberc Lung Dis 2006;10:559-64. 19. Vn Rie A, Enrson D. XDR tuberculosis: n indictor of public helth negligence. Lncet 2006;368:1554-6. 20. Chonde TM. The role of bcteriologic services in the Ntionl Tuberculosis nd Leprosy Progrmme in Tnzni. Bull Int Union Tuberc 1989;64:37-9. 21. Trébucq A, Angonou S, Gninfon M, Lmbregts K, Boulhbl F. Prevlence of primry nd cquired resistnce of Mycobcterium tuberculosis to ntituberculosis drugs in Benin fter 12 yers of short-course chemotherpy. Int J Tuberc Lung Dis 1999;3:466-70. 22. Heldl E, Arndottir T, Cruz JR, Trdencill A, Chcon L. Low filure rte in stndrdised retretment of tuberculosis in Nicrgu: ptient ctegory, drug resistnce nd survivl of chronic ptients. Int J Tuberc Lung Dis 2001; 5:129-36. 23. Dosso M, Bonrd D, Msellti P, Bmb A, Doulhourou C, Vincent V et l. Primry resistnce to ntituberculosis drugs: ntionl survey conducted in Cote d Ivoire in 1995-1996. Ivoirin Study Group on Tuberculosis Resistnce. Int J Tuberc Lung Dis 1999;3:805-9. 24. Uplekr MW, Sheprd DS. Tretment of tuberculosis by privte medicl prctitioners in Indi. Tubercle 1991;72:284-90. 25. Mhendrdht Y, Lmbert ML, Boelert M, Vn der Stuyft P. Editoril: Engging the privte sector for tuberculosis control: much dvoccy on megre evidence bse. Trop Med Int Helth 2007; (Feb):5. 26. Boulet LP, Phillips R, O Byrne P, Becker A. Evlution of sthm control by physicins nd ptients: comprison with current guidelines. Cn Respir J 2002;9:417-23. 27. Interntionl Stndrds for Tuberculosis Cre. Avilble t: http://www.who. int/tb/publictions/2006/istc_report.pdf 28. Newell JN, Pnde SB, Brl SC, Bm DS, Mll P. Control of tuberculosis in n urbn setting in Nepl: privte-public prtnership. Bull World Helth Orgn 2004;82:92-8. Donld A Enrson & Nils E Billo 29. Blsubrmnin R, Rjeswri R, Vijybhskr RD, Jggrjmm K, Gopi PG, Chndrsekhrn V, et l. A rurl public-privte prtnership model in tuberculosis control in South Indi. Int J Tuberc Lung Dis 2006;10:1380-5. 30. Globl DOTS Expnsion Pln. Progress in TB control in high-burden countries, 2001, one yer fter the Amsterdm Ministeril Conference. Genev: WHO; 2001 (WHO/CDS/STB/2001.11). 31. The Globl Fund for Tuberculosis, AIDS nd Mlri. Avilble t: http:// www.thegloblfund.org/en/funds_rised/distribution/#disese 32. Figuero-Munoz J, Plmer K, Poz MR, Blnc L, Bergstrom K, Rviglione MR. The helth workforce crisis in TB control: report from high burden countries. Hum Resour Helth 2005;3:2. 33. Strk O, Helmenstein C, Prskwetz A. Humn cpitl depletion, humn cpitl formtion, nd migrtion: blessing or curse? Economic Letters 60:363-367. 34. Green A, Collins C. Helth systems in developing countries: public sector mngers nd the mngement of contrdictions nd chnge. Int J Helth Plnn Mnge 2003;18:S67-78. 35. Externl Qulity Assessment for AFB Smer Microscopy. Wshington: Assocition of Public Helth Lbortories; 2002: 111 pges. 36. Foundtion for Innovtive New Dignostics. Avilble t: http://www. finddignostics.org/ 37. Hwken MP, Muhindi DW, Chky JM, Bhtt SM, Ng ng LW, Porter JD. Under-dignosis of smer-positive pulmonry tuberculosis in Nirobi, Keny. Int J Tuberc Lung Dis 2001;5:360-3. 38. Evns JR, Cstillo GT, Abed FH, et l. Helth reserch: essentil link to equity in development. New York: Oxford University Press; 1987; 1-136. 39. Ntionl Tuberculosis Assocition. Recommendtions of the Arden House Conference on tuberculosis. Am Rev Respir Dis 1960;81:482-4. 40. Hrries AD, Boxshll M, Phiri S, Kwnjn J. Mnging HIV nd tuberculosis in sub-shrn Afric. Lncet 2006;367:1817-8. 41. Huong NT, Duong BD, Co NV, Quy HT, Tung LB, Broekmns JF, et l. Tuberculosis epidemiology in six provinces of Vietnm fter the introduction of the DOTS strtegy. Int J Tuberc Lung Dis 2006;10:963-9. 42. Mris BJ, Gie RP, Hesseling AC, Schf HS, Lombrd C, Enrson DA, et l. A refined symptom-bsed pproch to dignose pulmonry tuberculosis in children. Peditrics 2006;118:e1350-9. 43. El-Sony AI, Mustf SA, Khmis AH, Enrson DA, Brk OZ, Bjune G. The effect of decentrliztion on tuberculosis services in three sttes of Sudn. Int J Tuberc Lung Dis 2003;7:445-50. 398 Bulletin of the World Helth Orgniztion My 2007, 85 (5)
Round tble discussion Round Tble Discussion Public privte mix DOTS in Indi LS Chuhn The bse pper highlights the chllenge of mintining the qulity of TB services while working with multiple sectors, nd this discussion is very relevnt to the Indin setting. Despite hving lrge network of stte government-owned public helth fcilities, significnt proportion of Indin ptients seek helth cre from the privte sector. 1 Numerous nongovernmentl orgniztions (NGOs) provide TB services. Moreover, mny lrge nd smll stte nd ntionl public-sector providers including rilwys, socil insurnce, ports, mines nd the rmed forces lso mnge lrge numbers of TB ptients but re not under the direct purview of the Revised Ntionl TB Control Progrmme (RNTCP). To ddress this, the RNTCP piloted nd documented innovtive public privte mix DOTS (PPM DOTS) models during the erly phse of expnsion. Evlution of these models provided evidence for dditionl TB cse detection with good tretment success rtes. 2 Subsequently, the RNTCP recognized PPM DOTS s strtegy to mnge TB ptients reporting to multiple sectors nd different types of helth-cre providers. From s erly s 2002, RNTCP hd expnded PPM DOTS ctivities country-wide using the progrmme guidelines for involvement of NGOs nd privte prctitioners. 3,4 The strtegy is built round developing DOTS tsk mix for ech provider type, with the RNTCP offering support for tsks tht the relevnt provider is unble to perform, such s defulter retrievl or lbortory qulity ssurnce. For medicl college involvement, stte-level nd ntionl tsk forces were creted. In 2003, the RNTCP lunched intensified PPM DOTS ctivities in 14 urbn districts. WHO-PPM medicl consultnts nd peripherl field supervisors were recruited nd posted to these districts. An expnded version of the existing routine RNTCP surveillnce system collected disggregted dt from the different helth-cre providers. Providers were involved through systemtic process of situtionl nlysis nd listing of helth-cre fcilities, sensitiztion nd trining of prctitioners on RNTCP, trining of RNTCP stff on PPM-DOTS, identifiction of fcilities for RNTCP service delivery, memornd of understnding nd RNTCP service delivery. The dt from the intensified PPM sites hve shown n overll increse in the number of TB cses notified under RNTCP. The stte government public helth deprtments remin the lrgest contributors to cse detection, followed by medicl colleges nd the NGO sector. The yield of cses from the privte sector to RNTCP hs not been proportionte to the numbers involved. This is becuse there re numerous privte clinics nd hospitls in urbn res which usully hve very low TB ptient lods. NGOs nd privte prctitioners contribute more to tretment observtion thn to cse detection. These findings hve highlighted nd reinforced the importnce of initilly prioritizing nd trgeting PPM-DOTS ctivities for those fcilities used by the lrgest numbers of ptients. The intensified PPM-DOTS ctivities strengthened the wider government helth sector s involvement in the progrmme, leding to incresed cse detection from this sector. Economic evlutions in Hyderbd, New Delhi nd Bnglore show tht PPM-DOTS is ffordble nd cost-effective, nd tht it reduces the finncil burden on ptients nd society. 5,6 Another evlution in Bnglore shows tht the intensified PPM inititive hs predominntly reched people from lower socio-economic groups. 7 Thus, lthough demnding in terms of efforts required, PPM DOTS is essentil in the longterm interests of ptients, providers nd progrmmes. Currently more thn 12 000 privte prctitioners, over 2000 NGOs, over 230 medicl colleges nd 110 corportesector helth fcilities re involved in RNTCP ctivities. The Indin Medicl Assocition is n importnt prtner of RNTCP t ntionl nd stte levels, nd hs dopted the Interntionl Stndrds for TB Cre. As the bse pper s uthors point out, RNTCP is wre tht dopting stndrds lone my not led to improved mngement prctices. This will require continuous enggement nd working in prtnership with the diverse providers. Building on their chievements, the RNTCP nd the Indin Medicl Assocition re working together to implement the PPM component of project recently pproved by the Globl Fund to Fight AIDS, Tuberculosis nd Mlri. O 1. Uplekr M, Juvekr S, Mornkr S, Rngn S, Nunn P. Tuberculosis ptients nd prctitioners in privte clinics in Indi. Int J Tuberc Lung Dis 1998; 2:324-9. 2. Dewn PK, Ll SS, Lonnroth K, Wres F, Uplekr M, Shu S, et l. Improving tuberculosis control through public-privte collbortion in Indi: literture review. BMJ 2006;332:574-8. 3. Involvement of non-governmentl orgniztions in the revised ntionl tuberculosis control progrmme. Delhi: Centrl TB Division, Directorte Generl of Helth Services, Ministry of Helth nd Fmily Welfre, Government of Indi; 2001. 4. Involvement of privte prctitioners in the revised ntionl tuberculosis control progrmme. Delhi: Centrl TB Division, Directorte Generl of Helth Services, Ministry of Helth nd Fmily Welfre, Government of Indi; 2002. 5. Cost nd cost-effectiveness of public-privte mix DOTS. Genev: WHO; 2004 (WHO/HTM/TB/2004.337). 6. Pntoj A, Ll SS, Lonnroth K, Chuhn LS, Uplekr M, Pdm MR, et l. Cost nd cost-effectiveness of scled-up nd intensive PPM DOTS in Bnglore. Int J Tuberc Lung Dis 2006;10:S281. 7. Unnikrishnn KP, Ll SS, Pntoj A, Lonnroth K, Chuhn LS, Jitendr R, et l. Economic nlysis of helth cre seeking behviour by tuberculosis ptients in Bnglore, Indi. Int J Tuberc Lung Dis 2006;10:S281. TB-DOTS in the Philippines: impct of decentrliztion nd helth sector reform Alberto G Romuldez b The bse pper by Enrson & Billo includes thoughtful ccount of the DOTS progrmme s development, from its inception following the Declrtion of Amsterdm, the World Helth Assembly resolution, nd the workshop of Ntionl TB Progrmme Mngers of 22 high-burden countries. Centrl TB Division, Directorte Generl of Helth Services, Nirmn Bhvn, New Delhi 110 001 Indi. Correspondence to LS Chuhn (e-mil: ddgtb@tbcindi.org). b M-Tech Medicl Hospitl, 379 Sen. Gil Puyt Ave., Bel-Air Villge, Mkti City 1209 Metro Mnil, Philippines. Correspondence to Alberto G Romuldez (e-mil: qusir@mozcom.com). Bulletin of the World Helth Orgniztion My 2007, 85 (5) 399
Round tble discussion As high-burden country, the Philippines prticipted in ll three milestone events. The story of DOTS implementtion in the country hd begun five yers before, when the WHO Regionl Director for the Western Pcific Region nd the newly ppointed Philippine Secretry of Helth greed in mid-1995 to give priority ttention to tuberculosis by llocting t lest hlf of the country s WHO funds (roughly US$ 2 million per biennium) to initite mjor TB control effort. By mid-1996, 16 out of the country s 77 provinces were selected s pilot sites. From the strt, the NTP hd to del with the dministrtive difficulties introduced by 1992 lw trnsferring responsibility for helth services to locl governments. By 1995 the Deprtment of Helth hd devolved control of helth service units to 77 provinces nd over 1600 cities nd municiplities. Nevertheless, the NTP s well-motivted, techniclly competent nd well-mnged stff ws ble to strt up the DOTS strtegy in ll 16 selected sites in less thn two yers. Lerning from the experience of other ntionl progrmmes, like immuniztion nd fmily plnning, NTP developed mechnisms to work with locl government units to implement its ctivities. Results of the Ntionl TB Survey of 1997 confirmed tht the Philippines, with n estimted prevlence of lmost hlf million cses, still hd mjor TB problem. This provided the impetus for ntionwide implementtion of the DOTS strtegy, which ws expnded strting in 1999. By the end of 2000, the Philippines reported 100% DOTS coverge. Menwhile, nlysis of ntionl helth expenditures led to helth sector reform gend tht significntly stremlined DOH opertions, beginning with the centrl office. In the ensuing centrl office stff reductions, NTP positions were reduced from 22 to 2 in 2001. However, subsequent stffing review enbled the restortion of 7 posts. Additionlly, NTP trined regionl helth office stff, who work closely with locl governments. NTP s 2000 dt showed tht DOTS ws implemented throughout the country, tht its tretment success rte ws 88% nd its cse detection rte ws 48%. To improve cse detection, NTP strengthened its links with the Philippines Colition Aginst Tuberculosis (n NGO of privte individuls nd institutions) by developing the public privte mix (PPM) DOTS pproch. The Ntionl Helth Insurnce Progrmme lso included implementtion of DOTS strtegy in its benefits pckge. DOTS thrives tody, thnks to locl nd ntionl politicl commitment, the support of WHO-WPRO, funding from the Globl Fund to Fight AIDS, Tuberculosis nd Mlri nd the introduction of the Globl Drug Fcility for procurement of DOTS supplies. It hs met the globl trgets with 75% cse detection nd 87% success rtes. Nevertheless, some concerns persist, such s whether such levels of commitment nd support cn be mintined for nother decde. Additionl concerns include the possible emergence of uncontrolled multidrugresistnt strins of TB nd increses in wht is now low nd slow HIV/AIDS sitution in the Philippines. A finl concern is whether the Ntionl Helth Insurnce Progrmme, pivotl in helth-cre finncing reform, cn expnd its coverge of the DOTS strtegy fst enough to cover nticipted reductions in externl support beyond 2010. O Lessons from the DOTS Expnsion Pln in Indonesi: highlighting humn resource development Crmeli Bsri, Petr Heitkmp b & Firdosi Meht b Indonesi rnks third mong the TB high-burden countries. A decde of TB control using the DOTS strtegy hs fcilitted progress towrds reching the 2005 interntionl trgets for TB control. Indonesi reported cse detection rte of 68% for 2005 nd success rte of 87% for the 2004 ptients cohort. The strong politicl commitment nd ledership shown by the Indonesin government from 1999 onwrds hve led to the development of tody s TB control strtegy. This commentry highlights three key pillrs towrds the chievement of the 2005 trgets. First, sound nd well-budgeted five-yer strtegic pln, 1 following the Globl DOTS Expnsion Pln s explined in Enrson & Billo s pper, lid the foundtion for implementtion nd ttrcted donor funding, including two grnts from the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (Globl Fund). Second, the NTP focused on humn resources development nd cscded trining through bilterl donor grnt. The cscded trining progrmme, which strted in lte 2000, llowed trining of different ctegories of stff. During the biennium 2002 2003, over 5000 (34.7%) doctors nd nurses t the helth-centre level were trined out of the totl pool of trinees estimted t 14 474. The helth ministry reports tht 98% of TB stff t helth centre fcilities nd pproximtely 24% of TB stff t hospitls re trined in DOTS. A core of mster triners t the regionl level initited nd supervised the plnning nd coordintion of trining ctivities. Trining ctivities were grdully shifted to the districts fter centrl trining group ws estblished to ct s ctlyst nd reference point in ccordnce with guidelines nd curricul. 2 Through the Globl Fund funding, s prt of the overll humn resource development pln, tems of mobile mster triners helped cler the trining bcklog t the helth-centre level. In ddition, trining coordintors re in plce t the NTP nd in most provinces. Third, mngement cpcity hs been strengthened t ll levels, with key inititive to estblish provincil DOTS tems s well s to decentrlize the Globl Fund mngement to district level. The Globl Fund hs cted s pull mechnism for improving surveillnce nd informtion flows. Indonesi is moving forwrd in implementing the new 2006 2010 five-yer pln for TB control 3 in line with the new Stop TB Strtegy. The 2004 prevlence survey 4 shows lrge geogrphicl difference in TB burden, reflecting the need for re-specific plnning, including doption of the Interntionl Stndrds for TB Control (ISTCs) mong ll helth-cre providers. This lso ddresses the chllenge of TB/ HIV in ffected provinces, nd prevents multidrug-resistnt TB by strengthening lbortory networks nd surveillnce. The involvement of ll helth-cre providers in Jv nd Bli prioritizes linkges between hospitls nd helth-cre centres. In estern Indonesi nd remote res of Sumtr, the min focus is on strengthening the most peripherl helth centres, Ntionl TB Progrmme of Indonesi, Jkrt, Indonesi. Correspondence to Crmeli Bsri (e-mil: c_bsri@yhoo.com). b WHO Indonesi Office, Jkrt, Indonesi. 400 Bulletin of the World Helth Orgniztion My 2007, 85 (5)
Round tble discussion supported by community-bsed schemes nd NGOs. Mny inconsistencies remin in trnslting these TB policies into locl plns nd budgets; fostering locl government commitment is relted chllenge. The 2006 2010 strtegic pln outlines strtegies ddressing these issues. The chllenge is to sustin momentum nd build on the foundtions lid in the first strtegic pln. O 1. Ntionl TB control progrm strtegic pln 2002-2006. Jkrt: Republic of Indonesi Ministry of Helth; 2001. 2. TB control curricul nd modules. Jkrt: Republic of Indonesi Ministry of Helth; 2000. 3. Frmework for TB strtegic pln in Indonesi: 2006-2010. Jkrt: Republic of Indonesi Ministry of Helth; 2006. 4. Tuberculosis prevlence survey in Indonesi. Jkrt: Directorte Generl of Communicble Disese Control nd Environmentl Helth, Republic of Indonesi Ministry of Helth; 2005. A new disese reporting system increses TB cse detection in Chin Liy Wn, Shiming Cheng b & Dniel P Chin c In the bse pper, Enrson & Billo provide criticl evlution of the Globl DOTS Expnsion Pln nd ddressed mny of the chllenges confronting globl tuberculosis control. They did not, however, elborte on one of the key chllenges the low percentge of infectious tuberculosis (TB) ptients identified nd treted in DOTS progrmmes. In this report, we describe key intervention tken by Chin to ddress this importnt problem. In 1992, Chin begn wide-scle implementtion of wht eventully becme known s the DOTS strtegy. In the hlf of Chin tht implemented this strtegy, the TB tretment success rte rpidly exceeded 85%. 1 However, during the 1990s, the TB cse-detection rte only reched 30% ntionwide. 2 The reson for the low cse-detection rte ws well known within Chin. Over 90% of ptients confirmed to hve TB initilly ccess cre in Chin s vst hospitl system, but less thn 30% of these ptients eventully end up in the Center for Disese Control nd Prevention (CDC) system where DOTS ws implemented. 3 Becuse most hospitls dignose TB using only chest X-rys, it cn only be confirmed fter evlution by the CDC, where sputum exmintion is lso used. In 1996, the Ministry of Helth (MOH) set up regultion requiring ll hospitls to report nd refer suspected TB ptients nd cses identified in these institutions to the CDC system for further follow-up. But this regultion proved difficult to enforce, becuse it ws difficult to monitor whether hospitls were in fct reporting nd referring ll their TB cses nd suspected cses. In 2003, the SARS epidemic broke out in Chin. The epidemic brought to light weknesses in the public helth system, especilly the problem of incomplete nd delyed reporting of SARS nd other communicble diseses. Following SARS, the government worked to improve the reporting of communicble diseses, revising the Lw on Controlling Infectious Diseses nd mking it legl requirement to report ll cses of 37 communicble diseses. 4 In Jnury 2004, the MOH lunched the ntionwide internet-bsed communicble disese reporting system. 5 By the end of 2005, 93.3% of 19 716 helth fcilities t nd bove the county level nd 66.1% of 38 518 township-level helth fcilities were using this system to report the country s 37 notifible diseses. The verge length of time to report from county-level helth fcility to the centrl level hs been reduced from 29 dys to 1 dy. The MOH hs instructed ll locl CDCs to regulrly visit hospitls t nd bove the county level nd to monitor the reporting nd referrl of suspected nd confirmed TB cses. As result, the number of these cses nd suspected cses reported by hospitls hs incresed. Hospitls re required to refer ll ptients suspected of hving TB or dignosed with it to the locl CDC for further evlution nd tretment. Some referred ptients report to the locl CDC nd some do not. Although the bsolute number of referred ptients coming to the locl CDC hs incresed over time, the percentge of ptients rriving on their own hs not. Every working dy, CDC stff members cross the country ccess the centrl dtbse to collect informtion on recently reported confirmed or suspected TB cses in their re. These stff members seek to contct ptients who fil to come to the locl CDC within three dys of being reported. In 2005, 686 742 confirmed or suspected TB cses were reported from the hospitl system. Among them, 301 938 (44%) cme to the CDC system by themselves for further evlution. Of the remining 384 804 ptients, the CDC ttempted to contct 282 706 (73.5%) of them, nd successfully found nd evluted 134 023 ptients (or 47.4% of those sought for follow-up). Overll, 435 961 (63.5%) of ll ptients reported by the hospitl system were eventully evluted by the CDC system. In 2005, Chin chieved the globl tuberculosis control trget of 70% cse-detection nd 85% tretment success. Of the 562 788 smer-positive tuberculosis cses reported in 2005, 127 467 (22.6%) were initilly reported by hospitls through the Internet. Thus implementtion of the system nd policies mentioned bove hs plyed n importnt role in tuberculosis cse detection. Nevertheless, to ensure tht even more ptients benefit from DOTS services, more work is needed to ensure tht higher percentge of referred cses get to the CDC before they re followed up, higher percentge of ptients re followed up, nd higher percentge of those who re followed up ctully rrive t the CDC system. O 1. Chen X, Zho F, Dunmu H, Wn L, Wng L, Du X, Chin DP. The DOTS strtegy in Chin: results nd lessons fter 10 yers. Bull World Helth Orgn 2002;80:430-6. 2. Globl tuberculosis control: surveillnce, plnning, finncing. WHO Report 2003. Genev: WHO: 2003 (WHO/CDS/TB/2003.316). 3. Report on ntionwide rndom survey for the epidemiology of tuberculosis in 2000. Beijing: Ministry of Helth; 2002. 4. Order of the Stte Council. Lw of the People s Republic of Chin on the prevention nd tretment of infectious diseses. Avilble t: http://www. chincdc.cn/n272442/n272530/n272907/n272922/6837.html 5. M JQ, Yng GH, Shi XM. Informtion technology pltform in Chin s disese surveillnce system. Dis Surveillnce. 2006;21:1-3. Ministry of Helth, Beijing, People s Republic of Chin. b Center for Disese Control nd Prevention, Beijing, People s Republic of Chin. c World Helth Orgniztion, Beijing, People s Republic of Chin. Correspondence to Dniel P Chin (e-mil: chind@chn.wpro.who.int). Bulletin of the World Helth Orgniztion My 2007, 85 (5) 401
Round tble discussion Building politicl commitment in Peru for TB control through expnsion of the DOTS strtegy Cesr Bonill & Jime Byon b In the context of public helth, Peru hs long history in the fight ginst TB. 1,2 In 1990, the Ntionl TB Control Progrm becme ntionl helth priority, receiving government support to estblish progrmme tht hs been model of efficiency t the globl level. 1 Mintining TB s sttus s ntionl helth priority requires significnt level of politicl commitment, s the bse pper noted. 3,4 However, in country like Peru where the helth sitution is closely relted to constnt chnge nd rpid socil trnsformtion, n importnt element in ensuring politicl commitment is positioning the Ntionl TB Control Progrm s the key plyer in TB mngement. This effort s bsic principles must be communicted to dministrtive, politicl nd finncil decision-mkers. Politicl commitment for TB control must be sustined despite chnging heds of government nd fluctuting politicl trends. An importnt element in ensuring politicl commitment lies in the prticiption of civil society nd TB ptient orgniztions in ll levels of TB control ctivities, including humn rights issues. 4 When ntionl priorities shift nd ttention is deflected, TB control efforts cn suffer. 3 This is exemplified by the negtive impcts tht resulted from helth sector reform efforts erly in the current decde. 5 Until pproximtely 2001, Peru ws on the pth to exceeding its Millennium Development Gols regrding TB control. In 2001 2003, the helth reform process cused deteriortion in TB cse-detection ctivities. 5 Since 2004, this trend hs been reversed, yet we must now redouble our efforts to chieve the Millennium Development Gols. We gree with the led rticle s comments relting to mintining qulity of services, nd the Peruvin experience shows tht expnsion of the DOTS strtegy hs lso llowed us to successfully identify nd intervene in high vulnerbility res with elevted risk of tuberculosis trnsmission. These res include the prison popultion, the mrginlized urbn popultion in extreme poverty, indigenous popultions, those with MDR-TB nd others co-infected with HIV. In 2004, the Ntionl TB Control Progrm ws strengthened by four functionl pillrs: coordintion, mngement, communiction nd coopertion. These entities ll shre the responsibilities of mngement, ledership nd ccountbility. To further ensure politicl commitment, technicl committee (from government offices of finnce nd logistics) nd n dvisory committee (NGOs, technicl nd finncil institutions, scientific nd cdemic institutions) were set up s essentil prts of the Ntionl TB Control Progrm. This type of prtnership hs been crucil in securing politicl commitment, s civil society nd the Ministry of Helth hve joined efforts to work s tem by shring ledership nd responsibility nd integrting ctivities under new orgniztionl culture. These politicl commitments come not only from the Ministry of Helth, but lso from other ministries such s Justice, Internl Affirs, Eduction nd others. Such commitments re in the process of being trnsferred to regionl nd locl levels. The prtnership plys n essentil role in mintining politicl commitment when leders chnge nd when helth services re decentrlized. Finlly, the politicl commitment gined in Peru cn be seen in ntionl budget priorities. In the pst 15 yers, the verge budget llocted to the Ntionl TB Control Progrm ws US$ 3 million per yer. In 2006, this ws rised to lmost US$ 10 million, representing substntil politicl commitment. 5 O 1. Helth, key to prosperity: successful stories in developing countries. Genev: WHO; 2002 (WHO/CDS/2004.4). 2. Globl tuberculosis control: surveillnce, plnning, nd finncing. Genev: WHO; 2002 (WHO/CDS/TB/2002.295). 3. Nunn, Pul et l. The reserch gend for improving helth policy systems performnce nd service delivery for tuberculosis control: WHO perspective. Bull World Helth Orgn, 2002;80(6):471-476. 4. Stop TB Prtnership. The Globl Pln to Stop TB, 2006-2015. Actions for life: towrds world free of tuberculosis. Int J Tuberc Lun Dis. 2006; 10(3):240-1. 5. Construyendo linzs estrtégics pr detener l Tuberculosis: L experienci perun. Lim: Ministerio de Slud, Dirección Generl de Slud de ls Persons; 2006. DOTS expnsion nd TB control: the cse of Mli Msoud Dr c & Alimt Nco d Bckground Mli is vst country in west Afric with popultion of 13.1 million nd surfce re of 1 241 000 km². Poverty is mjor problem, with 63.8% of popultion living below the poverty threshold. 1 Only 47% of popultion lives less thn 5 km from helth centre. 2 In 2002, DOTS ws lunched in Mli with finncil support from the Cndin Interntionl Development Agency nd technicl ssistnce from the KNCV Tuberculosis Foundtion, the World Helth Orgniztion nd other prtners. In 2005, the progrmme notified 4883 tuberculosis cses (34/100 000 popultion), fr below the WHO estimtes of 36 914 cses. 3 The TB cse detection rte for sputum smer-positive pulmonry ptients in 2005 ws 21%. Mli s HIV/AIDS epidemic seems to be less widespred thn in estern nd southern Afric, with n estimted 1.8% of the dult popultion being infected with HIV. 4 DOTS expnsion: chievements nd chllenges Among the chievements of the Globl DOTS Expnsion Pln mentioned by in the bse pper, Mli hs benefited from incresed externl nd internl finncil resources, in- Ntionl TB Progrm, Lim, Peru. Correspondence to Cesr Bonill (e-mil: cesrbon@yhoo.es). b Socios En Slud Sucursl PERU, Lim, Peru. c KNCV Tuberculosis Foundtion, Prkstrt 17, The Hgue 2501 CC, The Netherlnds. Correspondence to Msoud Dr (e-mil: drm@kncvtbc.nl). d Progrmme Ntionl de Lutte contre l Tuberculose, République du Mli. 402 Bulletin of the World Helth Orgniztion My 2007, 85 (5)
Round tble discussion terntionl technicl ssistnce nd the Globl Drug Fcility s provision of qulity nti-tb drugs. Lbortory dignosis hs been mjor chllenge in the initil phse of DOTS expnsion. With interntionl technicl ssistnce nd vilbility of dditionl humn nd finncil resources, the microscopy network hs been substntilly strengthened. In 2005, 3530 new sputum smer-positive ptients were notified, which represents 26% increse over 2001. During the 1990s nd in line with heth sector reform, verticl progrmmes were bolished or scled down considerbly. Mli hs experienced wht uthors refer to s competing fshions. Implementtion of ntionl TB control guidelines, supervision, monitoring nd evlution were hmpered by competing priorities. To ddress these chllenges, the helth ministry recruited more stff t the centrl level nd identified regionl supervisors. Strengthened monitoring nd evlution led to significnt improvement of tretment outcome in most regions. The tretment success rte for new sputum smer-positive ptients improved from 61% for 2002 cohort to 77% for mid-2005 cohort, while the defult rte significntly decresed from 29% in 2002 to 7% in mid-2005. With further decentrliztion of tretment, improved supervision nd ptients eduction, higher tretment success rtes my be chievble. Mli is still fr from the globl trget of 70% TB cse detection of sputum smer-positive pulmonry ptients. Focus group discussions with ptients hve shown tht trditionl helers ply n importnt role in the Mlin society. Preliminry results of opertionl reserch in the Siksso region hve shown tht trining nd sustinble collbortion with trditionl helers my improve TB cse detection. 5 The level of drug resistnce is not known, but it is not expected to be high mong new ptients, s the tretment filure rte mong new TB ptients is only 2%. The progrmme considers direct observtion of tretment cornerstone of its strtegy to minimize the risk of drug-resistnt TB cses emerging. A limited study in Bmko hs shown tht 10.1% of TB ptients re co-infected with HIV. There is need to intensify TB/HIV collbortive ctivities, to offer HIV testing nd counselling for TB ptients nd to ddress bottlenecks in dignosis nd mngement of TB/HIV co-infection. Despite significnt progress due to the DOTS expnsion in Mli, chllenges remin tht require strong ntionl nd interntionl prtnerships to chieve sustinble TB control. O 1. World development indictors. Wshington: World Bnk; 2006. 2. Poverty reduction strtegy pper implementtion report; Mli Country Report No. 05/439. Wshington: Interntionl Monetry Fund; 2005. 3. Globl tuberculosis control: surveillnce, plnning, finncing. Genev: WHO; 2006 (WHO/HTM/TB/2006.362). 4. Mishr V et l. HIV testing in ntionl popultion-bsed surveys: experience from the Demogrphic nd Helth Surveys. Bull World Helth Orgn 84:7;537-545. 5. Dr M, Berthé M, vn der Werf M, Nco A, Coulibly A. Impct of trining nd collbortion with trditionl helers on TB cse detection in Siksso region of Mli. Pris: World Lung Helth Conference; 2005. Bulletin of the World Helth Orgniztion My 2007, 85 (5) 403