TB Monitor International-India to expand DOTS program
Cure rates up as project grows
To a flurry of laudatory press coverage, India announced last month it plans to dramatically scale up its new TB program, from 147 million to 271 million people. Already, coverage rates are ahead of schedule by two years.
"Tom Frieden has done an absolutely phenomenal job," says World Health Organiza tion spokesman Kraig Klaudt, referring to the former director of TB control in New York City loaned to WHO to help oversee the roll-out of the country's new national TB program.
To some, Frieden's pivotal role in engineering the program's success is a mixed blessing. "The issue is that you cannot run a project for a billion people out of New Delhi," says Peter Hayward, PhD, the principal health specialist for the World Bank in the New Delhi office.
"What's been achieved so far has been due to an enormous effort on the part of the people in Delhi. But it's our very strong view that this [next step] will require decentralization. That means there needs to be an equal amount of strengthening occurring in the states."
Coverage under the two-year-old program has grown swiftly, from 18 million people at the end of 1989 to 135 million by the close of 1999. Under the new program, mortality has dropped from 29% to 4%, and cure rates are up from less than 50% before the new program was implemented to around 84% now.
"They've increased DOTS [directly observed therapy, short-course] coverage from 2% of the population to 15%," notes Klaudt. Often when a new program is rolled out so quickly, quality drops, he adds, but in this case, cure rates have increased, from 70% to 75% at the start of the new program to a current level of 85%.
India has a third of the world's TB cases, more than any other nation on earth. TB results in 400,000 deaths per year and costs the economy an estimated $3 billion annually. The new TB program, which implements the WHO-approved DOTS approach to TB control, was financed by a soft loan of $142 million from the World Bank.
The challenge now is for the central authority in New Delhi to shift gears, says Hayward. "It's no longer a technical issue. It's a question of developing more capacity within the system." The good news is that India is beginning to function less as a unitary state and more as a federal system, he says, although there's still a long way to go.
"Here you have the [Centers for Disease Control and Pre vent ion], but you also have the state programs, and that's where most of the work gets done," he notes. In India, most public health direction still comes happens at the top, in New Delhi.
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