Bulletin of the World Health Organization

DOTS expansion and TB control: the case of Mali

Masoud Darac, Alimata Nacod

Background

Mali is a vast country in west Africa with a population of 13.1 million and a surface area of 1 241 000 km². Poverty is a major problem, with 63.8% of population living below the poverty threshold.1 Only 47% of population lives less than 5 km from a health centre.2 In 2002, DOTS was launched in Mali with financial support from the Canadian International Development Agency and technical assistance from the KNCV Tuberculosis Foundation, the World Health Organization and other partners. In 2005, the programme notified 4883 tuberculosis cases (34/100 000 population), far below the WHO estimates of 36 914 cases.3 The TB case detection rate for sputum smear-positive pulmonary patients in 2005 was 21%. Mali’s HIV/AIDS epidemic seems to be less widespread than in eastern and southern Africa, with an estimated 1.8% of the adult population being infected with HIV.4

DOTS expansion: achievements and challenges

Among the achievements of the Global DOTS Expansion Plan mentioned by in the base paper, Mali has benefited from increased external and internal financial resources, international technical assistance and the Global Drug Facility’s provision of quality anti-TB drugs.

Laboratory diagnosis has been a major challenge in the initial phase of DOTS expansion. With international technical assistance and availability of additional human and financial resources, the microscopy network has been substantially strengthened. In 2005, 3530 new sputum smear-positive patients were notified, which represents a 26% increase over 2001.

During the 1990s and in line with heath sector reform, vertical programmes were abolished or scaled down considerably. Mali has experienced what authors refer to as “competing fashions”. Implementation of national TB control guidelines, supervision, monitoring and evaluation were hampered by competing priorities. To address these challenges, the health ministry recruited more staff at the central level and identified regional supervisors. Strengthened monitoring and evaluation led to significant improvement of treatment outcome in most regions. The treatment success rate for new sputum smear-positive patients improved from 61% for 2002 cohort to 77% for mid-2005 cohort, while the default rate significantly decreased from 29% in 2002 to 7% in mid-2005. With further decentralization of treatment, improved supervision and patients’ education, higher treatment success rates may be achievable.

Mali is still far from the global target of 70% TB case detection of sputum smear-positive pulmonary patients. Focus group discussions with patients have shown that traditional healers play an important role in the Malian society. Preliminary results of operational research in the Sikasso region have shown that training and sustainable collaboration with traditional healers may improve TB case detection.5

The level of drug resistance is not known, but it is not expected to be high among new patients, as the treatment failure rate among new TB patients is only 2%. The programme considers direct observation of treatment a cornerstone of its strategy to minimize the risk of drug-resistant TB cases emerging.

A limited study in Bamako has shown that 10.1% of TB patients are co-infected with HIV. There is a need to intensify TB/HIV collaborative activities, to offer HIV testing and counselling for TB patients and to address bottlenecks in diagnosis and management of TB/HIV co-infection.

Despite significant progress due to the DOTS expansion in Mali, challenges remain that require strong national and international partnerships to achieve sustainable TB control. ■


References

Affiliations

  • KNCV Tuberculosis Foundation, Parkstraat 17, The Hague 2501 CC, The Netherlands.
  • Programme National de Lutte contre la Tuberculose, République du Mali.
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