Planning and DOTS implementation
All 22 HBCs have strategic plans for DOTS expansion, though the plan for Thailand has still not been made available to WHO. However, the transition from planning to implementation, and from implementation to improvements in coverage and case detection has been slower than anticipated. The constraints described in this report are disappointingly similar to those identified in 2003,5 though financial shortages have become a lesser concern for some countries. NTP staff interviewed for the present report listed 13 constraints in the HBCs. Dominant among them was the lack of adequately trained staff; followed by poor monitoring and evaluation; inadequate infrastructure; weak laboratories; the failure of DOTS programmes to engage private practitioners and other public providers; and ineffective decentralization.
Short- and long-term strategic planning, with regular reviews of the plans and assessment of interventions, would help ensure commitment to a sustained course of action, even in the face of other crises that threaten to consume resources reserved for TB control. Viet Nam -- the only HBC to have reached the targets -- offers a good example of sustained commitment. Firm NTP leadership and careful planning, reinforced by strong political will, have guided the methodical expansion of DOTS.
NTPs will find it hard to act independently of other factors that influence TB control. The lack of qualified personnel needs to be addressed through Human Resource Development Plans, generated within the context of national plans to strengthen the health workforce. The plans must include mechanisms to improve staff recruitment, retention, and motivation, to ensure better in-service and pre-service training, and to make use of secondments of staff from academic institutions. PPM projects, and schemes to involve other public providers and facilities (NGOs, communities, hospitals, and workplace or corporate health care systems), should bring many more clinical staff and health facilities into the ambit of DOTS programmes. NTPs must also make the case for improved infrastructure -- working with government outside the health sector -- to help improve the access of patients to health services.
The decentralization of health systems has left some countries unable to improve the quality of TB control. Responsibility for planning and financing has been fully transferred to peripheral health services, but without sufficient technical capacity or political support to handle added responsibilities at the periphery.
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.16 These interventions will need to be offered through better collaborations between TB and HIV/AIDS control programmes. Most collaborative TB/HIV activities are so far being implemented in districts or regions, rather than on a national scale. Some NTPs have determined that DOTS programmes must perform more effectively before attention is paid to the TB/HIV interaction. And yet the case detection targets for 2005 are unlikely to be met without, for example, the systematic referral of TB suspects from VCT centres, and from other facilities that provide services for HIV/AIDS patients. High cure rates will not be guaranteed for HIV-infected TB patients unless there is better access to ART and cotrimoxazole preventive therapy, and better treatment of other opportunistic infections.
Among other constraints to DOTS expansion are the failure of drug supplies, inconsistent drug quality, and undeveloped drug policies. Appropriate drug policy depends, in part, on the prevalence of drug resistance, and vice versa. The WHO/IUATLD global DRS project currently includes all or part of 14 HBCs.6 It must be expanded to more areas within those countries, and to the remaining 8 HBCs, to obtain a true assessment of the magnitude of the problem worldwide. Poor laboratory networks remain a major obstacle to establishing high-quality surveillance systems. The control of MDR-TB will require the implementation of all components of the DOTS strategy, extended where appropriate as DOTS-Plus, to include the use of standardized regimens of second-line drugs for patients with resistant strains. Ultimately DOTS-Plus and testing for drug sensitivity will become an integral part of the DOTS strategy, and planning for MDR-TB control will become a routine component of NTP programme activities.