A health staff is responsible for supervising each aadministrative area or institution in the district, and uses the district TB register to monitor progress and outcome of treatment of all patients in that district. Patient infomation, including age and gender, is recorded. This provides the district or local health chief with rapid feedback on individual patient progress in the district and allows for the monitoring of the epidemic overall.
Cohort analysis is the key management tool used to evaluate the effectiveness of the overall TB control activities in any given area. A cohort of TB patients consists of all those sputum-smear positive TB patients registered during a certain time. Cohort analysis refers to the statistical breakdown of that cohort according to certain indicators, such as the number of cases diagnosed, treatment progress and treatment successes.
The quarterly smear conversion report and quarterly and annual cure rates, together with the treatment success rate, give any middle- or higher-level manager timely, concrete indicators of achievement or of problems requiring action such as low cure rate, high default rate, higher than expected proportion of sputum smear-negative PTB or extra-pulmonary TB, and lower than expected case detection rate.
In areas where the DOTS strategy is implemented, the recording and reporting system allows for targeted, individualized follow-up action to help patients who may not be making satisfactory progress, and a rapid managerial assessment of the overall performance of each institution, district, region or county. There is a strong system of accountability and a system of cross-checks that make false reporting of data difficult.
Logistical Aspects
Secure Drug Supply
Planning and maintaining drug stocks at all levels is a notoriously difiicult task for general health services. Where DOTS is implemented, however, an accurate recording and reporting system provides the information needed to plan and maintain adequate drug stocks, such as the number of cases in the different treatment categories notified the previous year, the standardized treatment regimen used in the NTP, and the existing stocks.
Network of Smear Microscopy Laboratories with Regular Quality Control
Laboratories with competent, trained, motivated and supervised general health service lab technicians are essential. General laboratory services facilitate the diagnosis of pulmonary tuberculosis (including the correct classification of cases in determining the appropriate treatment regimen) and monitoring of treatment of sputum smear-positive cases.
Supervision and Training
Supervision and on-going training are necessary to ensure quality of TB control services throughout the health care system. Each district should have an individual such as district TB coordinator responsible for implementing TB control activities (case-finding and treatment) in the district. In order to maintain quality of service, these district TB coordinators should be trained and supervised by someone at the provincial/regional level. In turn, the central level of the Ministry of Health is responsible for training and supervising the provincial/regional coordinators.
Primary health care workers should also receive basic training in TB control such as how to recognize thc symptoms of TB and refer suspected patients for accurate diagnosis and treatment.
Operational Aspects
The five elements of DOTS represent the basic minimum that is necessary for TB control. However, the implementation of the strategy requires flexibility, with adaptation to a broad range of contexts. The stage of the TB epidemic, availability of human and other resources, existing health infrastructure, the prevalence of HIV and MDR-TB, and the degree of mobilization of health personnel and the community have an impact on how DOTS is implemented. Two specific examples follow:
･ Health sector reform is one area that poses both threats and opportunities for TB control. Because DOTS functions as an integral part of primary health care, it is fully compatible with the aims of health sector reform including strengthening district-level decision making and action, and improving efficiency and cost-effectiveness of service delivery. In face DOTS can serve as a model for maintaining effective prevention and control activities within the context of primary health care delivery. However, health sector reform driven by economic targets rather than health priorities may result in piecemeal introduction of user charges where TB services are now free, reorganization of service delivery and other changes that may sometimes adversely affect health systems and TB control programmes by weakening the management system and outcome reporting.
･ The worsening impact of HIV/AIDS on the incidence of TB threatens to overwhelm not only otherwise effective TB control programmes, but also primary health care networks in general. In areas of high HIV prevalence, the DOTS strategy alone is not enough. The dual TB/HIV epidemic requires epidemiological, clinical and programmatic coordination between TB and HIV prevention and treatment programmes at all levels. This cohesiveness is essential for a strong health system. Initiatives include linking TB control activities to existing HIV prevention programmes and improving referral systems between different agencies in the district health system.
Table 2 illustrates the operational flexibility of the DOTS strategy using local solutions to direct observation of treatment as an example.
