Planning and DOTS implementation
13. All 22 HBCs had formulated an overall plan for DOTS expansion by the end of 2003. Detailed plans for major improvements in DOTS coverage, case detection and programme quality had been made by several countries, including India and Indonesia. However, strategic planning to overcome the constraints to TB control remains weak in several countries with low case detection or cure rates.
14. The six most common constraints identified were: lack of qualified staff; poor monitoring and evaluation; inadequate infrastructure; weak laboratory services; the failure of DOTS programmes to engage private practitioners and other public providers; and ineffective decentralization. The remedies required to overcome these constraints include: the development of staffing plans for TB control that are consistent with plans to strengthen the health workforce in general; public-private mix projects and schemes to involve other public providers and facilities; and the provision of adequate funding for, and the building of local capacity in, countries with decentralized health systems. Intersectoral cooperation will be critical in overcoming constraints that lie beyond the full control of NTPs.
15. The effectiveness of DOTS, and the prospects for expanding the strategy, are also limited by the failure of drug supplies, inconsistent drug quality, and inadequate drug policies. A consequence is the spread of drug resistance. Part of the remedy will be to establish testing for drug sensitivity as an integral part of DOTS programmes, to standardize treatment regimens for patients that have failed treatment, and to ensure that second-line drugs are available and properly used for patients with MDR-TB.
16. While the DOTS strategy must remain at the heart of TB control policy, a wider range of interventions will be needed to reduce TB burden in the countries most affected by HIV/AIDS, especially those in eastern and southern Africa. The recommended interventions are set out in WHO's Interim Policy on Collaborative TB/HIV Activities, but so far they are being carried out on a small scale, in districts or regions of countries, rather than nationally.