Research Article: Adapting the DOTS Framework for Tuberculosis Control to the Management of Non-Communicable Diseases in Sub-Saharan Africa

Date Published: June 10, 2008

Publisher: Public Library of Science

Author(s): Anthony D Harries, Andreas Jahn, Rony Zachariah, Donald Enarson

Abstract: Anthony Harries and colleagues discuss how the DOTS paradigm could be adapted for controlling diseases such as diabetes in resource-poor countries.

Partial Text: In sub-Saharan Africa (SSA), communicable diseases, particularly HIV/AIDS, tuberculosis (TB), and malaria, are still responsible for the greatest burden of morbidity and mortality [1]. However, non-communicable diseases (NCDs) are becoming a significant burden [1]. The Global Burden of Disease Study, conducted in 2001, showed that 20% of deaths in SSA were due to NCDs [2], and this burden is predicted to rise to 40% by 2020 [3]. Obesity, hypertension, diabetes mellitus, cardiovascular disease, asthma, chronic obstructive pulmonary disease, epilepsy, and mental illness are some of the important, chronic NCDs that pose significant challenges in terms of management and follow-up.

In 1994, with the estimated annual global TB incidence rate at 8 million and the annual TB death rate at 1–2 million, the World Health Organization (WHO) announced a global emergency and developed a framework for TB control. This framework, based on the pioneering work of Dr. Karel Styblo [15] and subsequently branded “DOTS” by WHO (directly observed therapy, short-course), incorporated an important five-point policy package (Box 1) [16]. Between 1995 and 2005, DOTS was successfully expanded to 190 countries, and 26 million people, most of them poor, were successfully treated with standardised anti-tuberculosis drug regimens [17]. One of the crucial components of DOTS is the registration, recording, and reporting format, which is used to determine the number of patients enrolled for treatment every quarter and, 12 months later, the quarterly cohort’s subsequent end-of-treatment outcomes. Case-finding and treatment outcome data at facility level, collected and collated at national level, provide country-level information on the burden of TB. These data also form the basis of national drug forecasting and procurement. Well-run TB control programmes prevent stock interruptions of anti-tuberculosis drugs through reliable drug forecasting and six-monthly procurement.

In 2001, we advocated to adapt the DOTS model for the delivery and monitoring of antiretroviral therapy (ART) in resource-poor countries [18]. The difference between the treatment of TB and that of HIV/AIDS is that the latter is required life-long. In the past six years, this model has been developed and used successfully to deliver and monitor ART for more than 145,000 patients in Malawi, a poor country with a gross domestic product of less than US$200 per annum [19–21]. One of the keys to the success of this ambitious programme, in a country with an under-resourced health care system and a grave shortage of skilled health care workers, has been the simplification of management protocols to match existing infrastructure. Nationwide implementation of these protocols has been achieved through standardised training, a focus on a small number of treatment regimens, and quarterly standardised supervision and monitoring.

In general, health systems in SSA are more oriented to managing acute problems than chronic diseases, but this will have to change if NCDs are to be properly diagnosed, treated, and prevented [23]. If life-long ART can be managed and monitored by the system described in the previous section, this paradigm could also be used for patients with NCDs.

Within a country, the DOTS paradigm for NCDs should be piloted in one or two facilities, and lessons learnt in these facilities should be used to assist national roll-out within the public sector. It will be important to get private sector participation; this has been achieved in Malawi with respect to ART (see Text S1). Regular supervision, through provincial health officers, with collection and collation of data from all facilities would provide strategic information at the national level.

There is a misconception that public health is synonymous with infectious disease control [30]. NCDs are the current public health problem in the industrialised world, and will become an increasing burden on health services in the developing world. Regular, accurate, and timely data on case numbers and treatment outcomes are a sine qua non for proper management. At present, no such systems exist in the general health sector in sub-Saharan Africa, and the simple approach we advocate could be the first in a series of steps (which include attention to life-long adherence to medication, self-management, peer support, and patient associations [31]) designed to improve the situation.



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