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Approximately 3.6 million cases of active tuberculosis (TB) go potentially undiagnosed annually, partly due to limited access to confirmatory diagnostic tests, such as molecular assays or mycobacterial culture, in community and primary healthcare settings. This article provides guidance for TB triage test evaluations. A TB triage test is designed for use in people with TB symptoms and/or significant risk factors for TB. Triage tests are simple and low-cost tests aiming to improve ease of access and implementation (compared with confirmatory tests) and decrease the proportion of patients requiring more expensive confirmatory testing. Evaluation of triage tests should occur in settings of intended use, such as community and primary healthcare centers. Important considerations for triage test evaluation include study design, population, sample type, test throughput, use of thresholds, reference standard (ideally culture), and specimen flow. The impact of a triage test will depend heavily on issues beyond accuracy, primarily centered on implementation.

'The struggle [against tuberculosis] has caught hold along the whole line and enthusiasm for the lofty aim runs so high that a slackening is no longer to be feared. If [...], Tuberculosis (TB) is an ancient disease, but not a disease of the past. After disappearing from the world public health agenda in the 1960s and 1970s, TB returned in the early 1990s for several reasons, including the emergence of the HIV/AIDS pandemic and increases in drug resistance. More than 100 years after the discovery of the tubercle bacillus by Robert Koch, what is the status of TB control worldwide? Here, we review the evolution of global TB control policies, including DOTS (directly observed therapy, short course) and the Stop TB Strategy, and assess whether the challenges and obstacles faced by the public health community worldwide in developing and implementing this strategy can aid future action towards the elimination of TB.

The article discusses the critical factors impeding the control of multidrug-resistant tuberculosis and the solutions required to address such factors. Critical weaknesses have been encountered in current approaches to the treatment and control of tuberculosis and attempts are being to address the same globally.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.03.041 Byline: Knut Lonnroth, Ernesto Jaramillo, Brian G. Williams, Christopher Dye, Mario Raviglione Abstract: The main thrust of the World Health Organization's global tuberculosis (TB) control strategy is to ensure effective and equitable delivery of quality assured diagnosis and treatment of TB. Options for including preventive efforts have not yet been fully considered. This paper presents a narrative review of the historical and recent progress in TB control and the role of TB risk factors and social determinants. The review was conducted with a view to assess the prospects of effectively controlling TB under the current strategy, and the potential to increase epidemiological impact through additional preventive interventions. The review suggests that, while the current strategy is effective in curing patients and saving lives, the epidemiological impact has so far been less than predicted. In order to reach long-term epidemiological targets for global TB control, additional interventions to reduce peoples' vulnerability for TB may therefore be required. Risk factors that seem to be of importance at the population level include poor living and working conditions associated with high risk of TB transmission, and factors that impair the host's defence against TB infection and disease, such as HIV infection, malnutrition, smoking, diabetes, alcohol abuse, and indoor air pollution. Preventive interventions may target these factors directly or via their underlying social determinants. The identification of risk groups also helps to target strategies for early detection of people in need of TB treatment. More research is needed on the suitability, feasibility and cost-effectiveness of these intervention options. Author Affiliation: World Health Organization, Geneva, Switzerland

Introduction 'When the elephants fight, the grass gets trampled'--this aphorism exemplifies the vigorous debate over the best approach to planning for development. The debate positions Jeffrey Sachs, (1) a proponent [...], The Global Plan to Stop TB 2006-2015 is a road map for policy-makers and managers of national programmes. It sets out the key actions needed to achieve the targets of the Millennium Development Goals relating to tuberculosis (TB): to halve the prevalence and deaths by 2015 relative to 1990 levels and to save 14 million lives. Developed by a broad coalition of partners, the plan presents a model approach combining interventions that can feasibly be supplied on the ground. The main areas of activity set out in the plan are: scaling up interventions to control tuberculosis; promoting the research and development of improved diagnostics, drugs and vaccines; and engaging in related activities for advocacy, communications and social mobilization. Scenarios for the planning process were developed; these looked at issues both globally and in seven epidemiological regions. The scenarios made ambitious but realistic assumptions about the pace of scale-up and implementation coverage of the activities. A mathematical model was used to estimate the impact of scaling up current interventions based on data from studies of tuberculosis biology and from experience with tuberculosis control in diverse settings. The estimated costs of the activities set out in the Global Plan were based on implementing interventions and researching and developing drugs, diagnostics and vaccines; these costs were US$ 56 billion over 10 years. When translated into cost per disability adjusted life year averted, these costs compare favourably with those of other public health interventions. This approach to planning for global tuberculosis control is a valuable example of developing plans to improve global health that has relevance for other health issues. Resume Le plan mondial Halte a la tuberculose 2006-2015 fournit des lignes directrices aux decideurs politiques et aux directeurs de programmes nationaux. Il presente les interventions cles necessaires a la realisation des objectifs du Millenaire pour le developpement concernant la tuberculose (TB), a savoir faire baisser de moitie, entre 1990 et 2015, la prevalence de cette maladie et la mortalite lui etant imputable et epargner 14 millions de vies. Mis au point par un vaste groupement de partenaires, le plan propose un modele de strategie associant des interventions faciles a mettre en oeuvre sur le terrain. Les principaux domaines d'activite prevus sont : Le passage a l'echelle superieure des interventions de lutte antituberculeuse, la promotion des travaux de recherche et developpement concernant des outils diagnostiques, des medicaments et des vaccins plus performants et l'engagement dans des activites connexes de plaidoyer, de communication et de mobilisation sociale. Des scenarios ont ete developpes pour aider au processus de planification : ils considerent les problemes a l'echelle mondiale et dans sept regions epidemiologiques. Ces scenarios reposent sur des hypotheses ambitieuses, mais realistes, quant au rythme de passage a l'echelle superieure et de developpement de la couverture des activites. Un modele mathematique a ete utilise pour evaluer l'impact du passage a l'echelle superieure des interventions en cours a partir de donnees d'etudes biologiques sur la tuberculose et de l'experience acquise dans divers contextes en matiere de lutte antituberculeuse. Les estimations de couts pour les activites prevues par le Plan mondial correspondent a la mise en oeuvre des interventions et aux travaux de recherche et developpement de medicaments, d'outils diagnostiques et de vaccins ameliores ; elles se montent a US$ 56 milliard sur 10 ans. Une fois convertis en couts par annee de vie corrigee de l'incapacite (DALY), ces chiffres supportent favorablement la comparaison avec ceux d'autres interventions de sante publique. Cette strategie de planification de la lutte contre la tuberculose au niveau mondial est un exemple utile de programme de developpement pour l'amelioration de la sante dans le monde, qui interesse d'autres problemes sanitaires. Resumen El Plan Mundial para Detener la Tuberculosis 2006-2015 es una hoja de ruta para instancias normativas y gestores de programas nacionales. En el se establecen las principales intervenciones necesarias para alcanzar las metas de los Objetivos de Desarrollo del Milenio relacionadas con la tuberculosis: reducir a la mitad la prevalencia de esta enfermedad y la mortalidad por esa causa para 2015 en comparacion con los niveles de 1990 y salvar asi 14 millones de vidas. Elaborado por una amplia coalicion de asociados, el plan presenta un modelo que combina diversas intervenciones que pueden aplicarse de forma viable sobre el terreno. Las areas principales de actividad contempladas en el plan son las siguientes: expansion de las intervenciones de lucha antituberculosa; promocion de la investigacion y el desarrollo de mejores medios diagnosticos, medicamentos y vacunas; y participacion en las actividades relacionadas con la promocion, las comunicaciones y la movilizacion social. Se desarrollaron distintos escenarios para el proceso de planificacion, considerando los problemas a nivel mundial y en siete regiones epidemiologicas. Los escenarios partian de hipotesis ambiciosas pero realistas sobre el ritmo de expansion y la cobertura de aplicacion de las actividades. Se utilizo un modelo matematico para estimar la repercusion de la expansion de las intervenciones actuales sobre la base de datos procedentes de estudios de la biologia de la tuberculosis y de la experiencia de la lucha antituberculosa en diversos entornos. Los costos estimados de las actividades establecidas en el Plan Mundial -correspondientes a la ejecucion de las intervenciones y la investigacion y el desarrollo de medicamentos, medios de diagnostico y vacunas- ascendian a US$ 56 000 millones a lo largo de 10 anos. Traducidos al costo por AVAD (anos de vida ajustados en funcion de la discapacidad) evitado, la cifra es mas baja que la de otras intervenciones de salud publica. Este metodo de planificacion del control mundial de la tuberculosis brinda un valioso ejemplo para elaborar planes de mejora de la salud mundial que revistan interes para otros problemas sanitarios. [TEXT NOT REPRODUCIBLE IN ASCI.]

Introduction Private health care providers play a prominent role in delivering curative services in the majority of low-income countries. (l-5) They are often the first point of contact for a [...], Over the past decade, there has been a rapid increase in the number of initiatives involving 'for-profit' private health care providers in national tuberculosis (TB) control efforts. We reviewed 15 such initiatives with respect to contractual arrangements, quality of care and success achieved in TB control. In seven initiatives, the National TB Programme (NTP) interacted directly with for-profit providers; while in the remaining eight, the NTP collaborated with for-profit providers through intermediary hot-for-profit nongovernmental organizations. All but one of the initiatives used relational 'drugs-for-performance contracts' to engage for-profit providers, i.e. drugs were provided free of charge by the NTP emphasizing that providers dispense them free of charge to patients and follow national guidelines for diagnosis and treatment. We found that 90% (range 61-96%) of new smear-positive pulmonary TB cases were successfully treated across all initiatives and TB case detection rates increased between 10% and 36%. We conclude that for-profit providers can be effectively involved in TB control through informal, but well defined drugs-for- performance contracts. The contracting party should be able to reach a common understanding concerning goals and role division with for-profit providers and monitor them for content and quality. Relational drugs-for-performance contracts minimize the need for handling the legal and financial aspects of classical contracting. We opine that further analysis is required to assess if such 'soft' contracts are sufficient to scale up private for-profit provider involvement in TB control and other priority health interventions. Engagement productif des prestateurs prives dans la lutte antituberculeuse : des benefices bien reels sans contrat Ieonin Au cours de la derniere decennie, on a observe une rapide augmentation du nombre d'initiatives impliquant des prestateurs de soins de sante prives (<>) dans les efforts de lutte contre la tuberculose. Nous avons analyse 15 de ces initiatives sous l'angle des dispositions contractuelles, de la qualite des soins et des succes obtenus dans la lutte antituberculeuse. Dans le cas de 7 d'entre elles, le programme national de lutte contre la tuberculose (PNT) traitait directement avec des prestateurs exercant une activite lucrative, tandis que dans le cadre des 8 autres, le PNT collaborait avec des prestateurs a but lucratif, par l'intermediaire d'organisations non gouvernementales a but non lucratif. Toutes ces initiatives sauf une faisaient appel aux prestateurs a but lucratif en passant avec eux des contrats relationnels << Medicaments contre prestations >>, c'est-a-dire que les medicaments leur etaient fournis gratuitement par le PNT a la condition explicite qu'ils les distribuent gratuitement aux patients et qu'ils respectent les directives nationales en matiere de diagnostic et de traitement. Nous avons constate que, pour l'ensemble des initiatives, 90% (plage de variation : 61 - 96 %) des nouveaux cas de tuberculose pulmonaire a frottis positif avaient ete traites avec succes et que le taux de detection de la tuberculose aurait augmente de 10 a 36 %. Nous avons conclu que les prestateurs a but lucratif pouvaient participer efficacement a la lutte antituberculeuse par l'intermediaire de contrats informels, mais bien definis sous l'angle de la condition : medicaments contre prestations. La partie contractante doit etre en mesure de parvenir a un accord concernant les buts et la repartition des roles avec les prestateurs a but lucratif et de surveiller le contenu et la qualite de leurs prestations. Les contrats relationnels de type Medicaments contre prestations n'exigent qu'une prise en compte minimale des aspects juridiques et financiers couverts par les contrats classiques. Nous sommes d'avis qu'une analyse plus poussee s'impose pour evaluer si ces contrats <> suffisent pour elargir la participation des prestateurs prives a but lucratif a la lutte antituberculeuse et a Ventajas de los contratos relacionales: contratacion productiva de proveedores privados en la lucha contra la tuberculosis En el ultimo decenio han proliferado rapidamente las iniciativas que recurren a proveedores de atencion sanitaria privados con animo de lucro en las actividades nacionales de lucha contra la tuberculosis. Examinamos los acuerdos contractuales, la calidad de la asistencia prestada y los resultados obtenidos en la lucha contra dicha enfermedad en 15 iniciativas de ese tipo. En siete de ellas, el Programa Nacional contra la Tuberculosis trabajaba directamente con proveedores con animo de lucro, y en las ocho restantes colaboraba con proveedores con animo de lucro a traves de organizaciones no gubernamentales no lucrativas. Exceptuando un caso, en todas las iniciativas se recurrio a <> para hacer participar a los proveedores con animo de lucro, esto es, el Programa les proporcionaba los medicamentos de forma gratuita, pero insistiendo en que se dispensaran tambien gratuitamente a los pacientes y con arreglo a las directrices nacionales en materia de diagnostico y tratamiento. Observamos que en todas las iniciativas el 90% (intervalo: 61%-96%) de los nuevos casos baciliferos de tuberculosis pulmonar habian sido tratados satisfactoriamente, y que las tasas de deteccion de casos aumentaron entre el 10% y el 36%. Nuestra conclusion es que los proveedores con animo de lucro pueden participar de forma eficaz en la lucha antituberculosa mediante contratos informales, pero bien definidos, de medicamentos por prestaciones. La parte contratante debe poder llegar a un consenso sobre los objetivos y el reparto de las funciones con esos proveedores, y vigilar el contenido y la calidad de sus servicios. Los contratos de medicamentos por prestaciones reducen al minimo la necesidad de ocuparse de los aspectos juridicos y financieros de los contratos ordinarios. Consideramos que es conveniente realizar un analisis en mayor profundidad para determinar si esos contratos simplificados bastan para extender masivamente la participacion de los proveedores privados con animo de lucro en la lucha contra la tuberculosis y en otras intervenciones de salud prioritarias. [TEXT NOT REPRODUCIBLE IN ASCII.]

[TEXT NOT REPRODUCIBLE IN ASCII] Introduction Globally, there are almost nine million new cases of tuberculosis (TB) each year, two million of which result in death. More than one-third of [...], Objective To assess the cost and cost-effectiveness of the Public-Private Mix DOTS (PPM-DOTS) strategy for tuberculosis (TB) control in India. Methods We collected data on the costs and effects of pilot PPM-DOTS projects in Delhi and Hyderabad using documentary data and interviews. The cost of PPM-DOTS was compared with public sector DOTS (i.e. DOTS delivered through public sector facilities only) and non-DOTS treatment in the private sector. Costs for 2002 in US$ were assessed for the public sector, private practitioners, and patients/attendants. Effectiveness was measured as the number of cases successfully treated. Findings The average cost per patient treated was US$111-123 for PPM-DOTS and public sector DOTS, and US$111-172 for non-DOTS treatment in the private sector. From the public sector's perspective, the cost per patient treated was lower in PPM-DOTS projects than in public sector DOTS programmes (US$ 24-33 versus US$ 63). DOTS implementation in either the public or private sectors improved treatment outcomes and substantially lowered costs incurred by patients and their attendants, compared to non-DOTS treatment in the private sector (US$ 50-60 for DOTS compared to over US$100 for non-DOTS). The average cost-effectiveness of PPM-DOTS and public sector DOTS was similar, at US$120-140 per patient successfully treated, compared to US$ 218-338 for non-DOTS private sector treatment. Incremental cost-effectiveness analysis showed that PPM-DOTS can improve effectiveness while also lowering costs. Conclusion PPM-DOTS can be an affordable and cost-effective approach to improving TB control in India, and can substantially lower the economic burden of TB for patients. Resume Cout et rapport cout/efficacite de la strategie PPM-DOTS dans la lutte contre la tuberculose: resultats obtenus en Inde Objectif Evaluer le cout et le rapport cout/efficacite de la strategie DOTS mixte, associant secteurs public et prive, dans la lutte contre la tuberculose (TB) en Inde. Methodes Des donnees relatives aux coots et aux effets de projets pilotes PPM-DOTS menes a Delhi et a Hyderabad ont ete rassemblees a partir de l'analyse de documents et d'entretiens. Le coot des projets PPM-DOTS a ete compare a celui de l'application de la strategie DOTS par le secteur public (c'est-a-dire la delivrance des prestations DOTS par des etablissements publics uniquement) et a celui d'un traitement non DOTS mis en oeuvre par le secteur prive. Les coots en US $ pour 2002 ont ete evalues pour le secteur public, les praticiens prives et les malades/les personnes qui les soignent. L'efficacite a ete mesuree par le nombre de cas traites avec succes. Resultats Le cout moyen par malade traite se montait a US $ 111-123 pour la strategie PPM-DOTS et les prestations de type DOTS par le secteur public et a US $111-172 pour le traitement non DOTS pratique par le secteur prive. Du point de vue du secteur public, le cout par malade traite eteit plus faible pour les projets PPM-DOTS que pour les programmes DOTS mis en oeuvre par le secteur public (US $ 24-33 contre US $ 63). Qu'elle soit appliquee par le secteur public ou prive, la strategie DOTS permet d'ameliorer les resultats therapeutiques et de reduire considerablement les coots supportes par les malades et les personnes qui les soignent par comparaison avec le traitement non DOTS applique par le secteur prive (US $ 50-60 pour la strategie DOTS contre plus de US $100 pour le traitement non DOTS). Les rapports cout/efficacite moyens pour la strategie PPM-DOTS et pour la strategie DOTS appliquee par le secteur public etaient similaires : US $120-140 par malade traite avec succes, a comparer a la valeur de US $ 218-338 obtenue pour le traitement non DOTS. Une analyse differentielle du rapport cout/efficacite a montre que la strategie PPM-DOTS permettait d'ameliorer l'efficacite tout en abaissant les couts. Conclusion La strategie PPM-DOTS est une approche peu onereuse et d'un bon rapport cout/efficacite pour faire progresser la lutte contre la tuberculose en Inde. Elle permet de reduire substantiellement la charge economique qu'impose aux malades cette pathologie. Resumen Costo y costoeficacia de la DOTS-PP contra la tuberculosis: datos de la India Objetivo Evaluar el costo y la costoeficacia de la estrategia DOTS publicoprivada (DOTS-PP) como medio de control de la tuberculosis en la India. Metodos Reunimos datos sobre los costos y los efectos de proyectos piloto de DOTS-PP llevados a cabo en Delhi y Hyderabad, utilizando para ello informacion documental y entrevistas. El costo de la DOTS-PP se comparo con el de la DOTS del sector publico (es decir, el tratamiento DOTS aplicado solo a traves de establecimientos del sector publico) y el del tratamiento distinto del DOTS en el sector privado. Se evaluaron los costos en US$ correspondientes a 2002 para el sector publico, los medicos particulares, y los pacientes/lasistentes, y la eficacia se midio como el numero de casos tratados satisfactoriamente. Resultados El costo medio pot paciente tratado fue de US$ 111-123 para la DOTS-PP y la DOTS del sector publico, y de US$ 111-172 para el tratamiento distinto del DOTS administrado en el sector privado. Desde la perspectiva del sector publico, en los proyectos DOTS-PP el costo por paciente tratado fue menor que en los programas DOTS del sector publico (US$ 24-33 frente a US$ 63). Tanto en el sector publico como en el privado, la aplicacion de la DOTS mejoro los resultados terapeuticos y redujo sustancialmente los costos para los pacientes y sus asistentes en comparacion con el tratamiento distinto del DOTS en el sector privado (US$ 50-60 para el DOTS, frente a mas de US$100 en el otro caso). La costoeficacia media del DOTS-PP y el DOTS del sector publico fue semejante, de US$ 120-140 por paciente tratado satisfactoriamente, frente a US$ 218-338 para el tratamiento no DOTS en el sector privado. El analisis de la costoeficacia marginal demostro que el DOTS-PP puede mejorar la eficacia reduciendo al mismo tiempo los costos. Conclusion El DOTS-PP puede ser una alternativa asequible y costoeficaz para mejorar el control de la tuberculosis en la India, y reducir sustancialmente la carga economica que acarrea la tuberculosis para los pacientes.

[TEXT NOT REPRODUCIBLE IN ASCII] Introduction Bangladesh ranks fifth among the 22 highest tuberculosis-burden countries in the world with an estimated tuberculosis (TB) incidence rate of 246 cases per 100 [...], In 1998, the Damien Foundation Bangladesh invited semi-qualified, private 'gram dakter' (Bangla for 'village doctors') to participate in tuberculosis (TB) programmes in a population of 26 million people in rural Bangladesh. The organization trained 12 525 village doctors to not only refer suspected TB cases for free diagnosis but also to provide directly observed treatment (DOT) free of charge. Source of referral and place of DOT was recorded as part of the standardized TB recording and reporting system, which enabled us to quantify the contribution of village doctors to case detection rates and also allowed disaggregated cohort analysis of treatment outcome. During 2002 and 2003, 11% of all TB cases with positive sputum smears in the study area had been referred by village doctors; the rate of positive tests in patients referred by village doctors was 14.4%. 18 792 patients received DOT from village doctors, accounting for between 20% and 45% of patients on treatment during the 1998-2003 period. The treatment success rate was about 90% throughout the period. Urine samples taken during random checks of treatment compliance were positive for isoniazid in 98% of patients treated by village doctors. Within the framework of Public-Private Mix DOTS, services provided by semi-qualified private health care providers are a feasible and effective way to improve access to affordable high quality TB treatment in poor rural populations. The large informal health workforce that exists in resource poor countries can be used to achieve public health goals. Involvement of village doctors in TB control has now become national policy in Bangladesh. Resume Medecine informelle et lutte contre la tuberculose au Bangladesh ou comment transformer en ressources des elements consideres comme des handicaps En 1998, la Fondation Damien au Bangladesh a invite des <> (terme local designant les <>) partiellement qualifies et prives a participer aux programmes de lutte contre la tuberculose (TB) dont beneficient 26 millions d'habitants des zones rurales du Bangladesh. Cette organisation a forme 12 525 medecins de village non seulement a orienter les cas suspects de TB vers un diagnostic gratuit, mais egalement a delivrer un traitement sous observation directe (DOT) gratuit egalement. La source de la notification et le lieu d'administration du traitement DOT ont ete enregistres dans le cadre du systeme standardise d'enregistrement et de notification des cas de TB, ce qui a permis de quantifier la contribution en pourcentage des medecins de village a la detection des cas et de realiser une analyse desagregee des resultats du traitement au sein de la cohorte. De 2002 a 2003, les medecins de village avaient notifie 11% de l'ensemble des cas de TB a frottis positif recenses dans la zone etudiee et dirige 14,4 % des patients presentant un test positif vers un specialiste. Ces medecins avaient egalement delivre un traitement DOT a 18 792 malades, soit une proportion de 20 a 45 % des malades sous traitement pendant la periode 1998-2003. Le taux de succes du traitement etait de 90% pour cette meme periode. Des echantillons d'urine preleves au hasard pour controler l'observance du traitement etaient positifs pour l'isoniazide chez 98 % des malades traites par des medecins de village. Dans le cadre des programmes DOTS mixtes public/prive, les services fournis par les dispensateurs de soins de sante partiellement qualifies et prives offrent aux populations rurales demunies un moyen efficace pour acceder plus facilement a un traitement antituberculeux de qualite. Il est donc possible de faire appel aux importants moyens humains de la medecine informelle dans les pays pauvres pour realiser les objectifs de sante publique. La participation des medecins de village a la lutte contre la TB fait maintenant partie de la politique nationale du Bangladesh. Resumen Aprovechar al maximo los recursos: medicos de aldea informales y control de la tuberculosis en Bangladesh En 1998, la Fundacion Damien de Bangladesh invito a <> (<> en bangla) privados semicualificados a participar en programas de tuberculosis para una poblacion de 26 millones de personas del Bangladesh rural. La organizacion capacito a 12 525 medicos de aldea no solo para derivar los casos sospechosos de tuberculosis a servicios de diagnostico gratuito, sino tambien para proporcionar gratuitamente tratamiento bajo observacion directa (DOT). La fuente de derivacion y el lugar de administracion del DOT se registraron como parte del sistema normalizado de registro y notificacion de la tuberculosis, lo que nos permitio cuantificar la contribucion de los medicos de aldea a las tasas de deteccion de casos y, ademas, efectuar analisis de cohortes desglosados de los resultados terapeuticos. Durante 2002 y 2003, el 11% de todos los casos de tuberculosis con baciloscopia de esputo positiva en el area de estudio fueron derivados por medicos de aldea; la tasa de pruebas positivas entre los pacientes derivados pot esos medicos fue del 14,4%. 18 792 pacientes recibieron DOT de los medicos ae aldea, lo que supone un 20%-45% de los pacientes sometidos a tratamiento durante 1998-2003. La tasa de exito terapeutico fue de alrededor del 90% durante el periodo considerado. Las muestras de orina obtenidas en los controles aleatorios del cumplimiento del tratamiento fueron positivas a la isoniazida en el 98% de los pacientes tratados por los medicos de aldea. En el marco de la DOTS publicoprivada, los servicios ofrecidos por dispensadores de atencion sanitaria privados semicualificados son una opcion viable y eficaz para mejorar el acceso a un tratamiento antituberculoso asequible y de calidad en las poblaciones rurales pobres. La amplia fuerza laboral sanitaria informal existente en los paises con pocos recursos puede ser aprovechada para alcanzar metas de salud publica. La participacion de medicos de aldea en la lucha contra la tuberculosis ha pasado a format parte de la politica nacional en Bangladesh.

Resume Partenariat public-prive pour la mise en ouvre de la strategie DOTS : quels sont les facteurs de succes? Objectif Comparer les processus de developpement et de realisation et les [...], Objective To compare processes and outcomes of four public-private mix (PPM) projects on DOTS implementation for tuberculosis (TB) control in New Delhi, India; Ho Chi Minh City, Viet Nam; Nairobi, Kenya; and Pune, India. Methods Cross-project analysis of secondary data from separate project evaluations was used. Differences among PPM project sites in impact on TB control (change in case detection, treatment outcomes and equity in access) were correlated with differences in chosen intervention strategies and structural conditions. Findings The analysis suggests that an effective intervention package should include the following provider-side components: (1) orienting private providers (PPs) and the staff of the national TB programme (NTP); (2) improving the referral and information system through simple practical tools; (3) the NTP adequately supervising and monitoring PPs; and (4) the NTP providing free anti-TB drugs to patients treated in the private sector. Conclusion Getting such an intervention package to work requires that the NTP be strongly committed to supporting, supervising and evaluating PPM projects. Further, using a local nongovernmental organization or a medical association as an intermediary may facilitate collaboration. Investing time and effort to ensure that sufficient dialogue takes place among all stakeholders is important to help build trust and achieve a high level of agreement. Keywords Tuberculosis Pulmonary/drug therapy; Antitubercular agents/supply and distribution; Private sector/utilization; Public sector; Directly observed therapy/utilization; National health programs/organization and administration; Health plan implementation; Intersectoral cooperation; Outcome and process assessment (Health care); Comparative study; India; Kenya; Viet Nam (source: MESH, NLM). Mots cles Tuberculose pulmonaire/chimiotherapie; Antituberculeux/ressources et distribution; Secteur prive/utilisation; Secteur public; Therapie sous observation directe/utilisation; Programme national sante/organisation et administration; Mise en oeuvre plan sanitaire; Cooperation intersectorielle; Evaluation resultats et methodes (Soins); Etude comparative; Inde; Kenya; Viet Nam (source: MESH, INSERM). Palabras clave Tuberculosis pulmonar/quimioterapia; Agentes antituberculosos/provision y distribucion; Sector privado/utilizacion; Sector publico; Terapia por observacion directa/utilizacion; Programas nacionales de salud/organizacion y administracion; Implementacion de plan de salud; Cooperacion intersectorial; Evaluacion de procesos y resultados (Atencion de salud); Estudio comparativo; India; Kenya; Viet Nam (fuente: DeCS, BIREME). [TEXT NOT REPRODUCIBLE IN ASCII.]

This paper is part of the PLOS Universal Health Coverage Collection. Universal Access and Social Protection in the Post-2015 Global TB Strategy The WHO has developed a post-2015 global tuberculosis [...], Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that 'No TB affected families experience catastrophic costs due to TB.' High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection.

Introduction Tuberculosis (TB) disease kills 1.4 million per year and remains a major global health problem [1]. Many low- and middle-income countries are unlikely to meet the Millennium Development Goals [...], Background: Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB- affected households) may worsen poverty and health. Extreme TB-associated costs have been termed 'catastrophic' but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs. Methods and Findings: From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2-4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%-43%) in the least-poor houses versus 48% (95% CI = 36%-50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs $20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%-61%] versus 38% [95% CI = 34%-41%], p < 0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7-15], p < 0.001), previous TB (OR = 2.1 [95% CI = 1.3-3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00-1.01], p = 0.02), and catastrophic costs (OR =1.7 [95% CI = 1.1-2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%-28%), similar to that of MDR TB (20% [95% CI = 14%-25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥ 10% or [greater than or equal to] 15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain 'dis-saving' variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients. Conclusions: Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary.

Vietnam has a well-organised National TB Control Programme (NTP) with outstanding treatment results. Excellent prospect of cure is provided free of charge. Still, some people prefer to pay for their TB treatment themselves in private clinics. This is a potential threat to TB control since no notification of cases treated in the private sector occurs, and there is no control of the effectiveness of treatment provided in private clinics. Using a qualitative approach within a grounded theory framework, this study explores health-seeking behaviour among people with TB, applying a specific focus on reasons for choices of private versus pubic health care providers. The study identifies a number of characteristics of private TB care, which both seem attractive to patients and at the same time contrast sharply with the structure of the NTP strategy. These include flexible diagnostic procedures, no administrative procedures to establish eligibility for treatment, flexible choices of drug regimens, non-supervised treatment (no DOT), no tracing of defaulters in the household, no official registration of TB cases and thus less threat to personal integrity. A possibility to demand individualised service through the use of fee-for-service payments directly to physicians also seems attractive to many patients. A number of the components of the NTP strategy that have been put in place in order to secure optimal public health outcomes are lacking in the private sector. A dilemma for TB control is that this seems to be an important reason for why many people with TB opt for private providers where quality of care is virtually uncontrolled. The global threat of TB has led to calls for forceful measures to control TB. However, based on the findings in this study it is argued that the use of rigid approaches to TB control that do not encompass a strong component of responsiveness towards the needs of individuals may be counterproductive for public health. [C] 2001 Elsevier Science Ltd. All rights reserved. Keywords: Tuberculosis control; Private health care; Health-seeking behaviour; DOT; Vietnam

We welcome the commentary 'Addressing Smoking Cessation in Tuberculosis Control' responding to the Bulletin theme issue on tuberculosis (May 2007), and thank the authors for raising this important issue. If [...]