Government commitment, diagnosis through microscopy, standardised and supervised treatment, uninterrupted drug supply, and regular monitoring, which together constitute DOTS—the WHO recommended tuberculosis control strategy—are all essential for controlling tuberculosis.
DOTS has helped make remarkable progress in global control of the disease over the past decade. The gain is evident: nearly 20 million patients have been cured of tuberculosis. However, global statistics suggest that DOTS alone is not sufficient to achieve the 2015 tuberculosis-related Millennium Development Goals (MDG) and the Stop TB Partnership targets.1 The need for a new strategy that builds on, and goes beyond, DOTS has also been recognised by the Second Ad-hoc Committee on the Global TB Epidemic2 and the 2005 World Health Assembly.3
In June, 2005, WHO's Strategic, Technical and Advisory Group on tuberculosis approved a new Stop TB Strategy, which was then endorsed by a 400-strong Stop TB Partnership meeting held in October, 2005. Many of the participants of that meeting—tuberculosis programme managers, technical and financial partners, researchers, policymakers, HIV/AIDS experts, health activists, and WHO staff—had contributed to the development of the strategy, which we summarise here.
Global tuberculosis control is facing major challenges today. First, much effort is still required to make quality care accessible without barriers of gender, age, type of disease, social setting, and ability to pay. Coinfection with Mycobacterium tuberculosis and HIV (TB/HIV), especially in Africa, and multidrug-resistant tuberculosis (MDR-TB) in all regions, but mainly in eastern Europe, make control complex and demanding. Weak health systems and services and scarcity of human resources pose great challenges to implementation. The organisation of standardised (and free) services within the public sector alone leaves out large numbers of patients, often including the very poor, to the largely unregulated non-state sector. Without effective engagement of patients and communities, services might not reach those who need them most. Finally, without commitment and wide support for development and deployment of new diagnostics, drugs, and vaccines, the goal of eliminating the disease might not be reached.
Since the development and promotion of DOTS in 1994–95, WHO and partners have been exploring innovative, complementary approaches to address the major constraints to controlling tuberculosis. Collaborative activities between tuberculosis and HIV/AIDS control programmes have been defined and are being implemented.4 Strategies to manage MDR-TB have been developed and tested.5 Effective ways of undertaking community care to support patients and expand access have been identified.6 Evidence-based strategies for engaging diverse public, voluntary, corporate, and private providers to widen the network of tuberculosis services have been worked out.7 To ensure quality of care across all providers, the International Standards for TB Care have been developed.8 Initiatives that also strengthen primary respiratory care while expanding quality services for tuberculosis have been piloted.9 Innovative mechanisms, such as the Global Drug Facility and the Green Light Committee, have been established to improve access to quality drugs for tuberculosis and MDR-TB, respectively.10,11 Options for tackling poverty in tuberculosis control have also been investigated.12 New alliances and initiatives for development of new tools are beginning to produce results. Furthermore, there has been a renewed global commitment to expanding quality health systems and social protection, and tuberculosis care is now viewed as a basic human right. This fact is reinforced by the recently drafted Patients' Charter for Tuberculosis Care. Finally, new resources are becoming available for health systems and disease control from domestic and international sources, including from the Global Fund to fight AIDS, TB and Malaria, the World Bank, bilateral agencies, and philanthropic organisations.
Nowadays, tuberculosis control demands a comprehensive and sustained response that complements measures to address the social and environmental factors that increase the risk of developing the disease. In fact, poor people bear most of the burden of tuberculosis. WHO's new Stop TB Strategy must, therefore, be viewed as a key component of broader international, national, and local strategies to alleviate poverty and advance social development. The panel outlines the strategy with its goal, objectives, targets, and six main components.
The first component is to pursue quality DOTS expansion and enhancement. This component forms the foundation of the Stop TB Strategy and seeks to improve the effectiveness of the five elements of DOTS. Government commitment should extend to wider political commitment at national and local levels, and translate into increased and sustained financing and greater stewardship for health system strengthening to support tuberculosis control.3 Laboratory networks for sputum smear microscopy should be enhanced by phased introduction of culture and drug susceptibility testing, as well as new methods for diagnosis as they become available. Treatment support should be provided with the purpose of ensuring completion of treatment and cure, and avoiding emergence and spread of drug resistance, emphasising a patient-centred approach and leaving behind misperceptions about directly observed therapy. National drug management systems need to be strengthened to guarantee regular supply of quality-assured drugs. Monitoring and assessment should help measure not just programme performance, but also the impact of tuberculosis control interventions in achieving the MDGs.
Second, TB/HIV, MDR-TB, and other special challenges need to be addressed. HIV and tuberculosis programmes need to rapidly scale up collaborative activities in all relevant settings. Programmatic management of MDR-TB should be mainstreamed into national tuberculosis control measures. Risk groups such as slum dwellers, prisoners, migrants, drug users, and diabetics need focused attention and tailored approaches.
The third component is to contribute to health system strengthening. Success and sustainability of tuberculosis control will necessarily depend on the capacity of the general health system. Therefore, national programmes should engage proactively in harmonised system-wide efforts to align and improve policies, human resources, financing, management, service delivery, and information systems. At the same time, they should design, adapt, and share innovative implementation strategies that contribute to health system strengthening.
Fourth, is to engage all care providers. In many countries, tuberculosis care is often provided by a wide array of practitioners outside national programmes, including private and corporate providers as well as some public-sector providers, such as those who work in prisons, general hospitals, and medical colleges. WHO's public-private mix approach has generated considerable evidence and produced guidance on the ways of involving all care providers to strengthen tuberculosis control. Scaling-up of public-public and public-private mix approaches will help increase case detection, standardise case management, save costs for the patients and the health system, and improve access and equity in care provision.7
To empower people with tuberculosis and communities is another component. Some of the key tasks in control—identifying people with tuberculosis, giving treatment support, and keeping simple records—lend themselves to be shared by the communities under guidance and support from local health services. To be empowered, patients and communities need the required knowledge and tools and a supportive environment. Communities that mobilise themselves to address tuberculosis will help improve care, reduce stigma, and enhance political commitment.
Finally, research is an integral component of the new Stop TB Strategy. This includes both operational research to continuously improve programme performance and biomedical research to develop new methods for tuberculosis control—diagnostics, drugs, and vaccines. This component will require increased global commitment to research and development and promotion of public-private partnerships for the purpose. High-burden countries should increase demand for new tools, participate in research, and facilitate their rapid roll-out.
The Stop TB Strategy, equipped with the lessons from DOTS implementation in diverse country settings, field-tested approaches to tackle current challenges, renewed efforts in developing new tools, and a strong Stop TB Partnership of all stakeholders, comprehensively addresses the problem of tuberculosis. The strategy also provides the basis and the context to the recently launched Global Plan to Stop TB, 2006–15.1 This plan exploits the various synergies and new approaches, and carries an estimated cost of US$56 billion over the decade. With a strategy and related plan, the framework to succeed is in place. However, the financing gap of $31 billion requires substantial increases in domestic and international commitment. Focusing on endemic countries, WHO and all Stop TB partners will intensify their efforts to help achieve the 2015 Partnership's targets and step towards eliminating this ancient scourge of humanity.
Conflict of interest statement
M C Raviglione is Director and M W Uplekar is Medical Officer of WHO's Stop TB Department.
The Lancet 2006; 367:952-955
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