Directly observed therapy and treatment adherence

Abstract

Jimmy Volmink and colleagues1Volmink J Matchaba P Garner P Directly observed therapy and treatment adherence.Lancet. 2000; 355: 1345-1350Summary Full Text Full Text PDF PubMed Scopus (150) Google Scholar introduce a timely and important sense of realism to the difficulties in organising a successful programme of tuberculosis control with the DOTS strategy.2WHO WHO Tuberculosis Programme: Treatment of Tuberculosis-guidelines for national programmes. WHO/TB/97.220, Geneva1997Google Scholar They describe two characteristics of successful DOT programmes that are insufficiently stressed. These are that programmes require the leadership of highly motivated individuals working in a government-funded system, or external support in the form of technical expertise and financial leverage.Our experiences in rural South Africa and conversations with colleagues around the world suggest that these observations are accurate. Following the DOTS strategy requires a high degree of knowledge and motivation. Complex decisions on treatment regimens and doses have to be made based on the knowledge of sputum smear results taken on three occasions during a long course of treatment. To achieve this health service management, transport, drug supplies, and laboratories need to be reliable. All may be weak in the poor and middle-income countries where tuberculosis is prevalent.WHO need to take these observations seriously. If successful DOT programmes depend on such individuals or external support, what will happen with health-service reforms and integration into primary health care? As tuberculosis care is decentralised, it will become increasingly difficult for even the most dedicated clinician (or district coordinator) to supervise. Furthermore the integration (and disintegration) of tuberculosis services into primary health care might lead to withdrawal of external funding as mechanisms for direct supervision are weakened. Such an effect has been seen with catastrophic consequences for people with tuberculosis in Zambia.3Bosman MCJ Health sector reform and tuberculosis control: the case of Zambia.Int J Tuberc Lung Dis. 2000; 4 (in press).PubMed Google ScholarWe remain committed to the broad principles of the DOT strategy. However, if it is to survive integration and delivery from primary health care it will need simplified drug regimens, and reduced requirements for sputum smears and documentation. Another alternative is the preservation of tuberculosis teams integrated within district health services.4Wilkinson D Tuberculosis and health sector reform: experience of integrating tuberculosis services into the district health system in rural South Africa.Int J Tuberc Lung Dis. 1999; 3: 938-943PubMed Google Scholar Jimmy Volmink and colleagues1Volmink J Matchaba P Garner P Directly observed therapy and treatment adherence.Lancet. 2000; 355: 1345-1350Summary Full Text Full Text PDF PubMed Scopus (150) Google Scholar introduce a timely and important sense of realism to the difficulties in organising a successful programme of tuberculosis control with the DOTS strategy.2WHO WHO Tuberculosis Programme: Treatment of Tuberculosis-guidelines for national programmes. WHO/TB/97.220, Geneva1997Google Scholar They describe two characteristics of successful DOT programmes that are insufficiently stressed. These are that programmes require the leadership of highly motivated individuals working in a government-funded system, or external support in the form of technical expertise and financial leverage. Our experiences in rural South Africa and conversations with colleagues around the world suggest that these observations are accurate. Following the DOTS strategy requires a high degree of knowledge and motivation. Complex decisions on treatment regimens and doses have to be made based on the knowledge of sputum smear results taken on three occasions during a long course of treatment. To achieve this health service management, transport, drug supplies, and laboratories need to be reliable. All may be weak in the poor and middle-income countries where tuberculosis is prevalent. WHO need to take these observations seriously. If successful DOT programmes depend on such individuals or external support, what will happen with health-service reforms and integration into primary health care? As tuberculosis care is decentralised, it will become increasingly difficult for even the most dedicated clinician (or district coordinator) to supervise. Furthermore the integration (and disintegration) of tuberculosis services into primary health care might lead to withdrawal of external funding as mechanisms for direct supervision are weakened. Such an effect has been seen with catastrophic consequences for people with tuberculosis in Zambia.3Bosman MCJ Health sector reform and tuberculosis control: the case of Zambia.Int J Tuberc Lung Dis. 2000; 4 (in press).PubMed Google Scholar We remain committed to the broad principles of the DOT strategy. However, if it is to survive integration and delivery from primary health care it will need simplified drug regimens, and reduced requirements for sputum smears and documentation. Another alternative is the preservation of tuberculosis teams integrated within district health services.4Wilkinson D Tuberculosis and health sector reform: experience of integrating tuberculosis services into the district health system in rural South Africa.Int J Tuberc Lung Dis. 1999; 3: 938-943PubMed Google Scholar Directly observed therapy and treatment adherenceAuthors' reply Full-Text PDF