Chapter 6 - Implementing DOTS
There are three phases to DOTS implementation: a pilot project phase, an expansion phase and a maintenance phase. The different phases of implementation of DOTS in a particular setting require a different emphasis on the technical, logistical, and operational aspects of the strategy. The pilot stage emphasizes technical and operational aspects. The expansion stage emphasizes logistical aspects. Maintenance--or sustained effective TB control--emphasizes all three, but with a nurturing of the political aspects.
Pilot Projects
Careful planning is necessary when implementing the DOTS strategy in countries. Use of the existing health infrastructure facilitates initial implementation. The first step is to implement the strategy in a few demonstration and training districts. When these demonstration and training districts are fully implementing the strategy and are demonstrating high cure rates, they can serve as the training sites for staff from other districts in the same region. The demonstration and training districts test the feasibility of implementing all aspects of DOTS, integrated with the general health services.
Expansion
Expansion throughout the whole county takes place in stages and requires emphasis on training, monitoring and supervision. Demonstration and training districts serve as training sites for staff in districts which themselves become the demonstration and training sites in other regions. The regional demonstration and training districts then serve as training sites for staff from other districts in the same region. In this way, over a period of about 5 years, the strategy expands step by step throughout the whole county. After some time, when there is maximum use of the existing health infrastructure, the emphasis shifts to mobilization of the community to contribute to country-wide implementation.
Maintenance
The challenge after country-wide expansion is to maintain effective performance over time. In the maintenance phase training is important--training for new staff becausc of turnover, refresher training, and training for innovations. Politicians and decision-makers must be convinced of the economic returns that justify long-term investment--both commitment and funding--in TB control.