Chapter 7 - DOTS in Low-incidence Countries
Most industrialised countries can allocate more human, technical and economical resources to health care than developing countries, and are provided with a better health infrastructure. In these countries, TB incidence is generally much lower than in developing countries, and the annual risk of infection in the general population is low. A major issue in these settings is maintaining adequate expertise in TB control at all levels.
Typically, in low-incidence countries the majority of TB cases occur in the elderly or in defined risk groups among the indigenous population and in young adults among foreign-born persons from high-prevalence countries. In some of these countries, the percentage of cases among foreign-born is as high as 50-70 percent.
Interventions additional to the essential core of the DOTS strategy may be appropriate in industrialised countries. This modified strategy would apply to countries where the basic policy package is already in place.
Chapter 8 - The Future of TB Control
A commitment to the future of TB control means that we must find ways to make better use of the DOTS strategy, we must accelerate research into new diagnostic tools, treatment options and vaccines, and we must encourage the mobilization of new partners in the fight against the epidemic.
Making Better Use of the Existing Strategy
Of all the WHO member states, 110 had accepted the DOTS strategy as of 1997. However, not all of these countries have implemented the strategy throughout the whole country. Several socio-economic and political constraints must be addressed immediately in order to ensure effective TB control reaches more of the world.
･ More funds must be allocated to TB control. Governments in some developing countries spend as little as $7 per capita on health care each year. In such situations, government health workers may be unable to obtain a regular supply of drugs and diagnostics, chronics will be created, cases will increase, people are likely to seek health care elsewhere or not at all, and the number of cases that go undetected is likely to rise.
･ Health sector reform should enhance, not jeopardize, TB control servicese. Health sector reform may result in piecemeal introduction of user charges, reorganization of service delivery and other changes that may sometimes adversely affect health systems and TB control programmes. Governments must be made aware that investing in and strerngthening TB control as part of the general health services will translate into future economic gains by ensuring a healthy population and workforce.
･ Health workers, especially in low-income countries, must be trained and compensated appropriately to ensure a motivated workforce. Ih some cases, health workers can survive only with iformal payments from their patients or by conducthg additional, private practice. This may create disincentives to best practice.
･ Governments must take ownership of TB as a national problem rather than relying solely on international agencies to combat the disease. If TB programmes are reliant on external funding, for example from donors, rather than government support, they may be difficult to sustain in the long term.
･ Physicians must support the implementation of DOTS and be a full partner in TB control efforts. Some doctors prefer to emphasize individual clinical judgement and drug regimens, while others may feel threatened by the fact that the strategy can be delivered by less highly trained workers. The full participation by doctors in the private sector is required for more widespread use of DOTS.
･ Countries must not tolerate TB as an inevitability. In cultures where TB is socially tolerated, there is unlikely to be a zealous commitment to reducing the burden of the disease.
