The “vertical–horizontal” debates: time for the pendulum to rest (in peace)?

413Bulletin of the World Health Organization | May 2007, 85 (5) Public health classics This section looks back to some ground-breaking contributions to public health, reproducing them in their original form and adding a commentary on their significance from a modern perspective. To complement the theme of this month’s issue, Mukund Uplekar & Mario C Raviglione review a paper by Halfdan Mahler on tuberculosis programmes in developing countries that was published in the Bulletin of the International Union against Tuberculosis and Lung Disease (1966;37:77-82). The paper is reproduced here in full. The “vertical–horizontal” debates: time for the pendulum to rest (in peace)? Mukund Uplekara & Mario C Raviglionea a Stop TB Department, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland. Correspondence to Mukund Uplekar (e-mail: uplekarm@who.int). doi: 10.2471/BLT.07.041756 (Submitted: 28 February 2007 – Accepted: 2 March 2007) “Historia magistra vitae” said Cicero: history is the teacher of life.1 It is an inevitable law of nature that unless there is a solid foundation of the past, no secure edifice of the future can be raised. Those who do not look at the past cannot devise means for the future; and unless the future is built on the past, it will be raised merely on stubble.2 The article on tuberculosis (TB) programmes in developing countries published in The Bulletin of the International Union against Tuberculosis and Lung Disease (1966; 37:77-82; reproduced here in full)3 four decades ago illustrates how past efforts to control TB could and should inform future interventions. Dr Halfdan Mahler, WHO Director- General from 1973 to 1988, spent a decade in India beginning in the early 1960s and was instrumental in designing what became a blueprint for a national tuberculosis programme in a developing country. As WHO’s Director-Gen- eral he later promoted the concept of primary health care (PHC), eliciting extensive global support and initiating the health–for-all movement. Like the swing of a pendulum, both PHC and global TB control efforts subsequently suffered a decline.4 The pendulum has, however begun to swing in the opposite direction. TB programmes have been reinforced and the PHC concept is being revived by WHO’s new Director-General, Dr Margaret Chan (http://www.who.int/dg/speeches/2007/ eb120_opening/en/index.html). The challenges facing national TB pro- grammes today include TB/HIV co- infection, multidrug-resistant TB (MDR-TB), health sector reforms, effective community engagement and a need for new tools for diagnosis, treat- ment and prevention. These problems seem more complex, yet the fundamen- tal approaches discussed in Mahler’s article are still central to TB control and to addressing these current challenges. In addition to raising some pertinent ques- tions, this commentary draws four key messages from the article that deserve the attention of all concerned: policy- makers, programme managers, scientists and activists. Sporadic efforts to control TB are wasteful A third of the world’s population is in- fected with TB, but the tools currently available cannot identify who will be responsible for producing millions of infectious cases of TB in the foreseeable future. The history of TB demonstrates that “Any sporadic effort in tuberculosis, however spectacular, will be wasteful; and it is wholly unrealistic to propose crash programmes with the objective of eliminating TB within a ten-year period”. This is perhaps the most im- portant message of Mahler’s article. Notwithstanding some new tools that are emerging, this statement is as true today as it was four decades ago. TB control demands sustained and stead- fast efforts on the part of everyone concerned. Programme management is distinct from patient management National TB programmes, as the article rightly suggests, ought to be a system with organizational and administra- tive features that allow pursuit of the optimal set of actions within the resources available to countries, cur- rently and in the near future, leading to specific and systematic reduction of the TB problem. It draws attention to the tendency to confuse the individual TB patient with the public health problem of TB and of identifying the operational conditions for a hospital, clinic or research project with those of the programme. The recent outbreak of extensively drug-resistant TB (XDR-TB) in a hospi- tal in South Africa, and demonstration of its presence worldwide in diverse set- tings, raised an outcry and continues to receive media attention. Conversely, it is common to read accounts of spectacular demonstrations of managing TB in a small district or a project area by a vol- untary or a research organization. Both failures and successes need to be viewed 414 Bulletin of the World Health Organization | May 2007, 85 (5) Special theme – Tuberculosis control The “vertical–horizontal” debates Mukund Uplekar & Mario C Raviglione in the larger context, with an eye on scalability and appropriate lessons drawn to inform the national programme and to ensure that basic TB control is not derailed. “The NTP does not emerge by simply pooling or multiplying sanatoria, clinics, research projects, rehabilitation centres, etc. … there is no escape from having as the primary objective, the sys- tematic reduction of the TB problem.” This calls for a strong national pro- gramme sustained over a period of de- cades, taking into consideration “what is technically desirable for a few and what is operationally feasible for the many”. Understandably, the article repeat- edly draws attention to developing countries’ limited resources and the need to match actions to these available resources. With public health receiv- ing increasing attention and resources globally, the current situation is better. Also thanks to the “globalization of solidarity”5 and the pressure of activism, mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNITAID have been created. As a consequence, unprecedented funding is now available to poor countries to address specific public health problems of global concern. In this scenario, Dr Mahler’s advice to countries would very likely be about sustainability, ac- countability and performance. Integrate, not disintegrate As they come straight from someone who was both a TB stalwart and a “father” of PHC, Dr Mahler’s thoughts on strengthening general health services and integrating TB control are highly rel- evant to these current debates. Although it was penned years before the 1978 International Conference on Primary Health Care, in Alma-Ata, the article foreshadows the PHC concept that was to later occupy the centre stage in inter- national public health. PHC’s origins seemed to be rooted, as does its current revival, in “an acute shortage of medical personnel in developing countries for all major public health priorities including tuberculosis”. To address the then-prevailing hu- man resource crisis, the paper suggests that “the staff of multi-purpose health centres can be trained in a few weeks in standard techniques of diagnosis, treat- ment, and immunization” and declares that “all communicable disease campaigns have overwhelmingly demonstrated that only through falling back on strong basic health services in developing countries is it possible to achieve an effective consoli- dation of these campaigns”. Does this mean that the national TB programmes should be fully integrated into general health services? While advo- cating that TB services indeed be thus inte- grated, Dr Mahler clarifies that integration, far from being a laissez-faire approach, requires “maximum involvement of all spe- cialized personnel such as programmers, organizers, tutors and assessors”. Furthermore, he warns that “train- ing (of multi-purpose workers) is of no avail – yes, even potentially harmful, if the techniques are not employed within the supervisory framework of a programme having pre-determined efficiency forecasts and built-in control of actual achievements”. He addresses the doubts related to integration in conclud- ing that, “… a TB programme first and foremost needs specialists in epidemiol- ogy, operational research, programming, training and evaluation”. And finally, “no amount of lip-service to planning, training and evaluation will bring out the benefit … to the receiving end without a unifying central direction with adequate powers to enforce and, when necessary, modify the national programme”. It is unclear why, despite this clarity about the need for specialist attention, the TB programme within WHO experi- enced a rapid decline in PHC’s heyday. Dr Mahler, in 1966 at least, visualized a TB programme that maintained and monitored a supervisory structure to ensure delivery of essential first-level TB care integrated into general health services. As for strengthening general health services, his expectation and that of WHO’s new Stop TB Strategy 6 has been that “the integrated TB programme … will grow organically together with the health services, each strengthening the other by adding to the confidence they inspire in public”. In the artificial dichotomy of vertical and horizontal approaches, the truth, like a pendulum, rests in-between. What is effective? The article concludes by emphasiz- ing four conditions for implementing effective national TB programmes in developing countries, which again are as relevant today as they were in 1966. First, programmes should be planned based on a “systematic analysis of exist- ing epidemiological and socio-economic situation”. This highlights the need to look into social and economic deter- minants to understand what factors beyond TB programmes and health sys- tems sustain the TB epidemic at current levels. Second, “training and retraining of all specialized and multi-purpose health personnel” is essential, especially on managerial aspects in addition to technical basics. This remains a weak- ness to be adequately addressed in many settings. Third, there must be a built-in evaluation at all levels, including impact evaluation “to serve as the conscience of the programme”. Finally, the article stresses the need for “a unifying central direction with adequate powers” indi- cating true political commitment. The masterstroke the article offers is in de- scribing the two essential characteristics of TB programme managers: “emotional detachment to choose their programme priorities and the courage to stick to them under immense counter-pressures from vested interests”. Is this too tall an order in today’s world? O References 1. M. Tulli Ceceronis. De oratore ad quintum fratrem liber secundus. Available at: http://www.thelatinlibrary.com/cicero/oratore2.shtml 2. Ranade RD. Essays and reflections. Mumbai: Bharatiya Vidya Bhavan; 1964. 3. Mahler H. The tuberculosis programme in the developing countries. Bull Int Un Tuberc 1966;37:77-82. 4. Raviglione MC, Pio A. Evolution of WHO policies for TB control, 1948-2001. Lancet 2002;359:775-8. 5. Raviglione MC. Infectious diseases and globalization. Dolentium Hominum: Chiesa e Saluto nel Mondo 2007; 64. 6. Raviglione MC, Uplekar MW. WHO’s new Stop TB Strategy. Lancet 2006; 367:952-5. 415Bulletin of the World Health Organization | May 2007, 85 (5) Special theme – Tuberculosis control H . M AH LE R pe rs on 's na tu ra l r es is ta nc e fin al ly su cc ee de d in e lim in at in g th e ba ci lli o r w he th er th e ba ci lli su rv iv ed in a d or m an t s ta te fr om w hi ch th ey ca n be re -a ct iv at ed . B ut , w e do k no w th at th es e hu nd re ds o f m ill io ns o f in fe ct ed p er so ns a re b ou nd t o pr od uc e m ill io ns o f in fe ct io us so ur ce s o f t ub er cu lo si s o ve r t he n ex t d ec ad es . A ny sp or ad ic e ffo rt in tu be rc ul os is , h ow ev er sp ec ta cu la r, w ill , b ec au se o f th is u np al at ab le e pi de m io lo gi ca l f ac t, be w as te fu l; an d it is w ho lly u nr ea lis tic t o pr op os e cr as h pr og ra m m es w ith t he o bj ec tiv e of e lim in at in g tu be rc ul os is w ith in a te n- ye ar p er io d. Th er e ar e pr ob ab ly so m e 10 to 1 5 m ill io n pe rs on s i n th e de ve lo pi ng c ou nt rie s w ho to da y ar e ca pa bl e of tr an sm itt in g ba ci lli to th ei r f el lo w tr av el le rs . T he y ar e no t c on ce nt ra te d in th e to w ns o r i n an y pr ac tic al ly id en tif ia bl e a re as o r g ro up s, bu tr at he r ‘ sp la sh ed ’ o ve r t he w ho le na tio na l te rr ito ry . C al cu la tin g fr om a l ar ge n um be r of s am pl e su rv ey s in d ev el op in g co un tri es , a t t he m os t o ne q ua rte r o f t he in fe ct io us c as es o f t ub er cu lo si s a re li vi ng in u rb an , an d at le as t t hr ee q ua rte rs in ru ra l a re as . I s it th en lo gi ca l t o co nc en tra te th e fig ht a ga in st tu be rc ul os is o n th e qu ar te r liv in g in t he t ow ns ? O r is it no t ra th er o bv io us f ro m a co m m un ic ab le d ise as e po in t of v ie w t ha t th e tu be rc ul os is p ro gr am m e m us t be o n a co un try -w id e ba si s i f i t i s t o ha ve a si gn ifi ca nt e pi de m io lo gi ca l i m pa ct ? Fa r to o of te n, e ve n tu be rc ul os is w or ke rs o ve rlo ok th at it is u bi qu ito us M A N , w ith h is pr es en t a nd f ut ur e su ffe ri ng ca us ed b y tu be rc le b ac ill i, w ho r ep re se nt s th e re al p ro bl em th at m us t b e t he fo cu s o f t he tu be rc ul os is p ro gr am m e a nd it s p rio rit ie s. So ci ol og ic al su rv ey s in se ve ra l d ev el op in g co un tri es h av e s ho w n th at m or e t ha n 90 p er ce nt o f r el ia bl y di ag no se d ac tiv e ca se s of tu be rc ul os is w er e co ns ci ou s of s ym pt om s su gg es tiv e of tu be rc ul os is ; t ha t m or e th an 7 0 pe r c en t o f t he se s po nt an eo us ly e xp re ss ed w or ry o ve r t he se s ym pt om s; a nd th at m or e t ha n 50 p er ce nt n ot o nl y w er e c on sc io us an d w or rie d, b ut in de ed h ad ta ke n ac tio n to se ar ch fo r a lle vi at io n of th ei r s uf fe rin g - m os tly in v ai n! Is th en to da y' s s oc ia l c ha lle ng e in tu be rc ul os is no t t o m ak e ef fe ct iv e se rv ic es a va ila bl e to a ll th os e w ho a lre ad y su ffe r a nd w ho a re p re pa re d to a cc ep t h el p? S uc h a fe lt- ne ed o rie nt ed p ro gr am m e w ill g iv e m ax im um sti m ul at io n to th e co nf id en ce o f t he g en er al p op ul at io n in th e tu be rc ul os is se rv ic es b ut a t t he sa m e tim e th is pr og ra m m e w ill b e by fa r t he m os t e co no m ic al a nd w ill ta ke c ar e of th e m os t da ng er ou s c as es fr om a c om m un ic ab le d ise as e po in t o f v ie w . B ut d o th e de ve lo pi ng c ou nt rie s t he n ha ve th e ne ce ss ar y re so ur ce s a t t he ir di sp os al to fa ce tu be rc ul os is ef fe ct iv el y bo th a s a n ep id em io lo gi ca l a nd so ci al p ro bl em ? Y es , I b el ie ve so ,i f th ey h av e th e em ot io na l d et ac hm en t t o ch oo se th ei r p ro gr am m e pr io rit ie s ra tio na lly a nd th e co ur ag e to st ic k to th em u nd er th e im m en se c ou nt er -p re ss ur es fr om v es te d in te re st s. I s ho ul d no w li ke to a na ly se b rie fly th re e ke y va ria bl es re le va nt to a va ila bl e, re so ur ce s na m el y, fi rs t t he te ch ni ca l t oo ls, th en th e fin an ci al re so ur ce s, an d fin al ly th e pe rs on ne l. Le t m e s ta rt w ith ca se -f in di ng . Ev er yb od y l iv in g i n a gi ve n ep id em io lo gi ca l si tu at io n is m ar ke d w ith a c er ta in ec ol og ic al pr ob ab ili ty of en co un te rin g tu be rc le ba ci lli ; of t he se b ac ill i be in g s uc ce ss fu lly t ra ns m itt ed ; of t he se s uc ce ss fu lly t ra ns - m itt ed b ac ill i p ro du ci ng d is ea se ; of t hi s di se as e sp on ta ne ou sl y h ea lin g o r re su lti ng i n de at h. W ith in t hi s ra ng e o f ris ks t he re i s a w el l-m ea ni ng t en de nc y to i de nt ify a pe rs on a s a p ot en tia l ca se o f tu be rc ul os is n ot o nl y b ef or e h e b ec om es i nf ec tio us 78 H . M AH LE R T ub er cu lo si s U ni t, W H O , P al ai s de s N at io ns , G en ev a, S w it ze rl an d ‘I t i s ba d pu bl ic h ea lth p ra ct ic e to tr ea t a c as e of in fe ct io us tu be rc ul os is a t h om e' . If y ou c an no t ac hi ev e at l ea st 9 5% t re at m en t su cc es s, d o no t tr ea t; `E m ph as is sh ou ld b e on c he m op ro ph yl ax is b ec au se it is e pi de m io lo gi ca lly to o la te to tr ea t t he ac tiv e ca se o f t ub er cu lo si s’ . T he se s ta te m en ts a re c as ua lly p ic ke d fr om th e vi nt ag e of a dv ic e gi ve n to d ev el op in g co un tr ie s in r ec en t m on th s. H ow is it p os si bl e to g iv e su ch m is le ad in g ad vi ce ? Pr ob ab ly b ec au se o f a la ck o f re co gn iti on t ha t a na tio na l tu be rc ul os is p ro gr am m e in a d ev el op in g co un tr y is a hi gh ly c om pl ex s ys te m in w hi ch o rg an iz at io na l a nd a dm in is tr at iv e fe at ur es a re fa r m or e im po rt an t t ha n, fo r in st an ce , t he th er ap eu tic d if fe re nc e be tw ee n a tw o- a nd a th re e- dr ug re gi m en o r th e ep id em io lo gi ca l d if fe re nc e be tw ee n a ba ct er io lo gi ca lly pr ov en a nd a n X -r ay s us pe ct c as e. W ha t is m or e, t ub er cu lo si s w or ke rs t en d to id en tif y th e op er at io na l c on di tio ns o f a h os pi ta l, a cl in ic , o r a re se ar ch p ro je ct w ith th os e of a n at io na l t ub er cu lo si s pr og ra m m e. T he co ns eq ue nc e of co nf us in g th es e m ic ro sy st em s w ith th e N at io na l T B Pr og ra m m e is h ig h- lig ht ed b y an a na ly si s of t he t ub er cu lo si s bu dg et a nd t he po pu la tio n ef fe ct iv el y co ve re d by e xi st in g tu be rc ul os is s er vi ce s in d ev el op in g co un tr ie s. O ft en m or e th an 8 0 pe r c en t o f a ll ex pe nd itu re o n tu be rc ul os is is se en to b e co ns um ed b y pe rs on al iz ed s er vi ce s ca te ri ng f or l es s th an 5 t o 10 p er c en t of t he tu be rc ul os is p ro bl em , w he re as le ss th an 2 0 pe r c en t o f a ll ex pe nd itu re is in ve st ed in co m m un ity se rv ic es fo r t he re m ai ni ng 9 0 to 9 5 pe r c en t o f t he tu be rc ul os is p ro bl em . T he n at io na l tu be rc ul os is p ro gr am m e do es n ot em er ge b y si m pl y po ol in g or m ul tip ly in g sa na to ri a, c lin ic s, r es ea rc h pr oj ec ts , re ha bi lit at io n ce nt re s, B C G ca m pa ig ns , et c. T he n at io na l tu be rc ul os is p ro gr am m e in a d ev el op in g co un tr y sh ou ld in st ea d be th e op tim al s et o f ac tio ns le ad in g to th e sp ec if ic a nd s ys te m at ic re du ct io n of th e tu be rc ul os is p ro bl em w ith in th e re so ur ce s at th e di sp os al o f th es e co un tr ie s to da y an d to m or ro w — a nd n ot i n th e ne xt c en tu ry . T hi s, t he n, i s th e m ac ro sy st em o f w hi ch I w ou ld p ro po se t o at te m pt a s ho rt a na ly si s to da y, s ta rt in g w ith t he t ub er cu lo si s pr ob le m , th en p ro ce ed in g w ith th e av ai la bl e re so ur ce s, a nd fi na lly m er gi ng th es e tw o ke y va ri ab le s in th e na tio na l p ro gr am m e. T he v er y re as on fo r o ur fa ilu re to a cc el er at e th e de pa rt ur e of tu be rc ul os is m ay to a la rg e ex te nt b e du e to a p ec ul ia r te nd en cy t o co nf us e th e in di vi du al w ith t he pr ob le m . It i s ad m itt ed ly m uc h ea si er t o st ar t w ith t he c on cr et e pa tie nt -d oc to r re la tio ns hi p th an w ith th e m or e ab st ra ct p ro bl em -r es ou rc e re la tio ns hi p, b ut fo r t he de ve lo pi ng c ou nt ri es t he re i s pr ob ab ly n o es ca pe f ro m h av in g as t he p rim ar y ob je ct iv e th e sy st em at ic r ed uc tio n of th e tu be rc ul os is p ro bl em . M or e th an h al f t he p op ul at io n liv in g in m os t de ve lo pi ng c ou nt ri es t od ay h av e al re ad y be en in fe ct ed b y tu be rc le b ac ill i. W e h av e no to ol s to re co gn iz e w he th er a 77 R ep ri nt ed fr om : B ul le tin o f t he In te rn at io na l U ni on a ga in st T ub er cu lo si s a nd L un g D is ea se 1 96 6; 37 :7 7- 82 w ith p er m is si on o f t he In te rn at io na l U ni on A ga in st T ub er cu lo si s a nd L un g D is ea se (T he U ni on ). 77 78 R ep ri nt ed fr om : B ul let in o f t he In te rn at io na l U ni on a ga in st Tu be rc ul os is an d Lu ng D ise as e 1 96 6; 37 :7 7- 82 w ith p er m iss io n of th e In te rn at io na l U ni on A ga in st Tu be rc ul os is an d Lu ng D ise as e (Th e U ni on ). 416 Bulletin of the World Health Organization | May 2007, 85 (5) Special theme – Tuberculosis control H . M AH LE R ce nt c ur e, to th e m os t e xp en si ve c os tin g 50 d ol la rs a nd g iv in g 95 to 1 00 p er c en t c ur e. If a de ve lo pi ng c ou nt ry is p re pa re d to c om m it its el f t o an o rg an iz ed c om m un ity p ro gr am m e in tu be rc ul os is , t he n th e ch oi ce o f r eg im en is a si m pl e fo rm ul a, n am el y, r ou gh ly th e an nu al dr ug b ud ge t d iv id ed b y th e es tim at ed n um be r o f n ew c as es fo un d pe r y ea r b y th e na tio na l pr og ra m m e. It is st ra ng e t ha t s til l s o fe w co un tri es ar e p re pa re d to ad op t t hi s s im pl e f or m ul a an d in st ea d pe rm it co st ly i nd iv id ua liz ed d ru g re gi m en s — i nc lu di ng s uc h en tir el y di sp en sa bl e ad di tiv es a s vi ta m in s — to s ta nd in th e w ay o f a ch ea p, s ta nd ar d, c om bi ne d pr im ar y dr ug tr ea tm en t f or a ll ca se s t ha t c an b e re lia bl y di ag no se d. La st b ut n ot l ea st l et u s no t ov er lo ok t he p re ve nt iv e to ol s. Fo r ob vi ou s fin an ci al a nd m an po w er re as on s, it is im po ss ib le to k ee p th e h un dr ed s o f m ill io ns o f i nf ec te d pe rs on s u nd er pe rio di ca l d ia gn os tic fo llo w -u p or u nd er co ve r o f d ru gs in o rd er to re du ce th e c on se qu en ce s of u na vo id ab le i nf ec tio n th at t ak es p la ce b ef or e th e ca se i s di sc ov er ed i n a re al is tic ca se -f in di ng p ro gr am m e. B ut t hr ou gh B C G i m m un iz at io n w e ha ve a 'tr ea tm en t' of t he ba ci lli a t th e ve ry m om en t th ey a re p ro du ci ng a p ot en tia l ca se o f tu be rc ul os is . Th er e pr ev ai ls a n al m os t u nc om fo rta bl e ag re em en t t ha t B C G v ac ci na tio n se em s t o of fe r t he m os t im po rta nt t oo l fo r re du ci ng t he f ut ur e su ff er in g ca us ed b y tu be rc ul os is i n de ve lo pi ng co un tri es . T hi s r el at iv e la ck o f c on tro ve rs y pr ob ab ly st em s f ro m th e co m fo rta bl e fa ct th at a s on e B CG v ac ci na tio n gi ve s a re m ar ka bl e p ro te ct io n fo r a d ec ad e o r m or e at th e c os t o f a fe w ce nt s, an ef fe ct iv e B C G p ro gr am m e co ul d be o pe ra te d w ith so m e 5 to 1 5 pe r c en t o f p re se nt ex pe nd itu re o n tu be rc ul os is in d ev el op in g co un tri es , a nd d oe s n ot , t he re fo re , j eo pa rd iz e th e m ai nt en an ce o f su ch s er vi ce s as r eh ab ili ta tio n or c he st su rg er y. H ow ev er , in s pi te o f its ap pe al in g ef fic ac y, c he ap ne ss a nd e as e of a pp lic at io n , B C G v ac ci na tio n is f ar , f ar f ro m be in g op tim al ly u se d in d ev el op in g co un tri es . Tu rn in g fr om th e te ch ni ca l t oo ls to th e fin an ci al re so ur ce s, an o pt im is tic a ss es sm en t o f na tio na l a nd in te rn at io na l e co no m ic p ro sp ec ts fo r t ub er cu lo sis c on tro l o ve r t he n ex t d ec ad e in di ca te s th at w e ca nn ot r ea lis tic al ly c ou nt o n m or e th an th e eq ui va le nt o f 5 to 1 0 ce nt s ex pe nd itu re p er h ea d in th e de ve lo pi ng c ou nt rie s. Th is c or re sp on ds to ro ug hl y 5 to 1 0 pe r ce nt o f t he to ta l h ea lth ex pe nd itu re p er h ea d be in g sp en t o n tu be rc ul os is c on tro l. N ow , t ak in g th e av er ag e m ill io n po pu la tio n in a d ev el op in g co un try , t he re w ill b e ea ch y ea r i n a fu lly de ve lo pe d tu be rc ul os is p ro gr am m e: so m e 50 00 n ew c as es to d et ec t a t a c os t o f s om e 10 ,0 00 do lla rs , s om e 7 00 0 ca se s t o be k ep t u nd er tr ea tm en t a t a co st of so m e 3 5, 00 0 do lla rs , a nd so m e 10 0, 00 0 EC G v ac ci na tio ns to b e do ne a t a c os t o f 5 00 0 do lla rs . T hi s to ta ls 5 0, 00 0 do lla rs . A dd t o th is am ou nt s om e 20 ,0 00 d ol la rs i n ex tra o ve rh ea d ex pe nd itu re f or t ra in in g, su pe rv is io n an d ev al ua tio n an d th e to ta l c om es to 7 0, 00 0 do lla rs o r 7 c en ts p er h ea d of th e po pu la tio n. In p rin ci pl e, th en , t he re a re n o ec on om ic o bs ta cl es to a n ef fe ct iv e tu be rc ul os is pr og ra m m e bu t i t s ho ul d no t b e ov er lo ok ed th at a t pr es en t ou t o f th e ap pr ox im at el y 5 ce nt s sp en t t od ay o n tu be rc ul os is p er h ea d of p op ul at io n, s om e 80 p er c en t a re b lo ck ed b y tra di tio na l s er vi ce s, su ch a s e sta bl ish in g an d m ai nt ai ni ng b ed s. Le t u s ho pe th at a t l ea st th e ne xt 5 a dd iti on al c en ts a llo ca te d to t ub er cu lo si s w ill b e dr ai ne d in to t he r ig ht p rio rit y ch an ne ls . Th ou gh i t i s th us p os si bl e to a ch ie ve a r at io na l — i f no t ha pp y — m ar ria ge b et w ee n fin an ci al r es ou rc es a nd t ec hn ic al k no w le dg e in a ny d ev el op in g co un try , w ha t ab ou t av ai la bi lit y of p er so nn el to c ar ry o ut th e pr og ra m m e? Th er e is a n a cu te s ho rta ge o f m ed ic al p er so nn el i n d ev el op in g c ou nt rie s fo r al l m aj or p ub lic h ea lth p rio rit ie s in cl ud in g tu be rc ul os is . W ha t is m or e, i n th e fr ee 80 T H E T U BE R CU LO SI S PR O G R AM M E IN T H E D E VE LO PI N G C O U N T R IE S bu t a lso a lm os t b ef or e he b ec om es in fe ct ed . B ut c as e- de fin iti on fo r t he s ak e of c as e- fin di ng m us t l og ic al ly b e re la te d to c as e- ac tio n. S in ce th e gr ea t m aj or ity o f a ct iv e ca se s ha ve o ne th in g in co m m on , n am el y th at th ey d ev el op sy m pt om s t ha t e ve nt ua lly m ot iv at e t he m to se ek he lp i f th ey h av e co nf id en ce i n th e he al th s er vi ce s, it is to t hi s gr ou p th at p er m an en t di ag no st ic fa ci lit ie s f irs t s ho ul d be m ad e av ai la bl e. F ur th er m or e, e m ph as is o n th e re lia bi lit y of t he d ia gn os is th ro ug h gi vi ng f irs t pr io rit y to b ac te rio lo gi ca l ca se -f in di ng s ec ur es op tim um u se o f s ca rc e tre at m en t r es ou rc es . T he n ex t p rio rit y w ill b e to in cl ud e th e gr ou p ha vi ng th e ne xt hi gh es t pr ob ab ili ty of su ff er in g fr om tu be rc ul os is , na m el y th e sy m pt om -m ot iv at ed , ba ct er io lo gi ca lly n eg at iv e pe rs on s, w ith p ro gr es si ve p ul m on ar y pa th ol og y as j ud ge d by X -r ay s ha do w s. It is u nl ik el y th at t he m aj or ity o f de ve lo pi ng co un tri es c an g o be yo nd th es e tw o pr io rit ie s o n a na tio na l s ca le d ur in g th e ne xt tw o de ca de s, bu t t he n th es e pr io rit ie s w ill n ot o nl y be in c on so na nc e w ith th e fe lt- ne ed o f t he p op ul at io n, bu t a ls o w ill , a s t he h ea lth s er vi ce s im pr ov e, le ad to e ar lie r d et ec tio n an d be tte r t re at m en t, an d th us to an in cr ea sin g fu sio n of ep id em io lo gi ca l a nd so ci ol og ic al o bj ec tiv es . B y st ic ki ng to th es e pr io rit ie s, a ge nu in e ca se o f t ub er cu lo si s c an b e di ag no se d at th e co st o f l es s t ha n fiv e do lla rs in a ny d ev el op in g co un try . N ev er th el es s, th er e ar e m an y de ve lo pi ng c ou nt rie s t ha t, lo ng b ef or e th ey h av e th es e pr io rit ie s, ar e em pl oy in g fu nd s an d pe rs on ne l o n sp as m od ic m as s X -ra y ef fo rts c ov er in g an in sig ni fic an t p ar t o f t he p op ul at io n. It is so m et im es fo rg ot te n th at m as s c he st ra di og ra ph y w as in tro du ce d in th e a ff lu en t c ou nt rie s a t a ti m e w he n th e f lo w of a tte nd er s a t c he st c lin ic s, ho sp ita ls , p ra ct iti on er s, et c. , w as v er y ad eq ua te ly ta ke n ca re o f an d, to a la rg e ex te nt , w as b eg in ni ng to le ss en th e pr es su re o n th es e fa ci lit ie s. It w as in tro - du ce d at a ti m e w he n th er e w as a re la tiv e ab un da nc e of c ap ac ity a nd sp ec ia liz ed m an po w er to ta ke c ar e of th e ad di tio na l c as es it d is co ve re d. T o ap pr oa ch th e pr ob le m in th e op po si te or de r in th e le ss r es ou rc ef ul c ou nt rie s is b ot h ba d ec on om y an d, in te rm s of s oc ia l a nd ps yc ho lo gi ca l a cc ep ta bi lit y, in ef fic ie nt . W ha t t he n ar e th e po ss ib ili tie s f or m at ch in g ra tio na l c as e- fin di ng w ith e ffe ct iv e tre at m en t? Th e la st W H O E xp er t C om m itt ee o n Tu be rc ul os is r ec om m en de d th at , a s th er e w as n o ev id en ce t ha t sp ec ia l be ne fit s re su lte d fr om h os pi ta liz at io n, a ll fin an ci al r es ou rc es a nd m an po w er a va ila bl e fo r tu be rc ul os is c on tro l in t he d ev el op in g co un tri es s ho ul d be co nc en tra te d on o rg an iz in g ef fic ie nt a m bu la to ry se rv ic es a nd n ot o n ru nn in g or c on st ru ct in g ne w b ed s. Th en it is s ai d, — a nd it is f or a ny d ev el op in g co un try to c ho os e be tw ee n a m od er n, sc ie nt ifi ca lly p ro ve d tre at m en t a pp ro ac h co st in g a fe w d ol la rs p er c as e tre at ed , o r tra di tio na l p ra ct ic e de m an di ng p ro lo ng ed h os pi ta liz at io n co st in g hu nd re ds o f do lla rs p er ca se . Th ou gh t he re i s pr et ty u ni ve rs al a gr ee m en t th at t he b ed o r th e di et o r th e in di vi du al iz ed a tte nt io n ar e no t cr iti ca l fa ct or s in c ur in g tu be rc ul os is , th er e is s til l a pr on ou nc ed te nd en cy to d em an d in sti tu tio na l c ap tiv ity b ec au se o f t he a lle ge d hi gh d ef au lte r ra te e nc ou nt er ed in th e am bu la to ry tr ea tm en t p ro gr am m e. P er m it m e to e m ph as iz e th at th e pa tie nt s i ni tia lly tr ea te d in h os pi ta ls p er se a re n o be tte r d ru g ta ke rs th an th e p at ie nt s i ni tia lly tre at ed in an e ffi ci en tly o rg an iz ed am bu la to ry p ro gr am m e. A s a m at te r o f f ac t, du e t o th e l ac k of i nt eg ra tio n in m os t co un tri es o f ex is tin g tu be rc ul os is b ed s in to t he a m bu la to ry co m m un ity p ro gr am m e, th e in st itu tio na l p at ie nt s t re at ed fo r a w ee k in a h os pi ta l u lti m at el y of te n fa re w or se th an th e am bu la to ry p at ie nt s. A s fo r t he c ho ic e be tw ee n in st itu tio na l a nd am bu la to ry tr ea tm en t, so fo r t he c ho ic e be tw ee n dr ug re gi m en s. Th e ch oi ce a m on g th e fir st -li ne d ru gs ra ng es fr om th e ch ea pe st c om bi na tio n co st in g 3 do lla rs a nd g iv in g 80 to 9 0 pe r 797 9 80 417Bulletin of the World Health Organization | May 2007, 85 (5) Special theme – Tuberculosis control T H E T U BE R CU LO SI S PR O G R AM M E IN T U D E VE LO PI N G C O U N T R IE S m ar ke t of s up pl y an d de m an d tu be rc ul os is do es n ot c ar ry s uf fic ie nt s oc ia l or e co no m ic pr es tig e va lu e to a ttr ac t ei th er t he q ua nt ity o r th e qu al ity o f do ct or s an y tra di tio na l sp ec ia liz ed tu be rc ul os is p ro gr am m e w ou ld re qu ire . F or tu na te ly th e st af f o f a m ul ti- pu rp os e he al th c en tre c an to da y be tr ai ne d w ith in a fe w w ee ks in s ta nd ar d te ch ni qu es o f d ia gn os is , tre at m en t a nd im m un iz at io n, b ut th is tr ai ni ng is o f n o av ai l — y es , p er ha ps ev en p ot en tia lly ha rm fu l — i f th e te ch ni qu es a re n ot e m pl oy ed w ith in t he s up er vi so ry f ra m ew or k of a pr og ra m m e ha vi ng p re -d et er m in ed e ffi ci en cy fo re ca sts a nd b ui lt- in c on tro l of a ct ua l ac hi ev em en ts. Th er ef or e, su ch a tu be rc ul os is pr og ra m m e, fir st an d fo re m os t ne ed s sp ec ia lis ts in e pi de m io lo gy , o pe ra tio na l r es ea rc h, p ro gr am m in g, tr ai ni ng an d ev al ua tio n. It is un fo rtu na te t ha t tu be rc ul os is sp ec ia lis ts of te n be lie ve t ha t to c ar ry o ut t he se f un ct io ns ef fe ct iv el y do es n ot e nt ai l an y sp ec ia l kn ow le dg e be yo nd t he c lin ic al ‘ kn ow -h ow ’ of di ag no sis a nd tr ea tm en t. Th e ba si s f or a ra tio na l s yn th es is o f t he tu be rc ul os is p ro bl em a nd th e av ai la bl e re so ur ce s in d ev el op in g co un tri es t od ay h as b ee n su cc in ct ly f or m ul at ed b y th e la st W H O E xp er t C om m itt ee o n Tu be rc ul os is in fo ur p rin ci pl es : a. Ep id em io lo gi ca l c on si de ra tio ns re qu ire th at a n at io na l t ub er cu lo si s p ro gr am m e m us t b e on a c ou nt ry -w id e an d pe rm an en t b as is — n ot sp or ad ic o r p at ch y. b. So ci ol og ic al c on si de ra tio ns d em an d th at th e na tio na l t ub er cu lo si s p ro gr am m e m us t s at isf y th e ex ist in g fe lt- ne ed s b ef or e it pr om ot es th e aw ar en es s o f n ew o ne s. c. A dm in is tra tiv e co ns id er at io ns m ak e it m an da to ry th at th e tu be rc ul os is se rv ic es be in te gr at ed in to th e ge ne ra l h ea lth se rv ic es . d. Ec on om ic c on si de ra tio ns re qu ire th at th e pr og ra m m e be su ch th at it s a pp lic at io n on a n at io na l s ca le is w ith in th e re so ur ce s a va ila bl e. I b el ie ve th e fir st tw o pr in ci pl es , n am el y, th e ep id em io lo gi ca l a nd s oc io lo gi ca l M U ST S ar e lo gi ca l i nf er en ce s f ro m th e dy na m ic s o f t ub er cu lo sis a s a c om m un ic ab le d ise as e pr ob le m w ith it s u bi qu ito us p re se nc e in ru ra l a nd u rb an a re as , a s w el l a s a s oc ia l p ro bl em e xp re ss in g its el f in t he m aj or ity o f ac tiv e ca se s of t ub er cu lo si s be se ec hi ng t he h ea lth s er vi ce s fo r al le vi at io n of th ei r s uf fe rin g. Th e la st p rin ci pl e, n am el y, t he s tri ct ly u ns en tim en ta l a dj us tm en t o f th e pr og ra m m e to ec on om ic re al iti es sh ou ld , I b el ie ve , b e q ui te o bv io us fr om w ha t I ju st sa id ab ou t t he fi na nc ia l re so ur ce s. I ha ve , s o fa r, no t s pe ci fic al ly r ef er re d to th e th ird p rin ci pl e, n am el y, th at a dm in ist ra tiv e co ns id er at io ns m ak e it m an da to ry th at th e tu be rc ul os is se rv ic es b e in te gr at ed in to th e ge ne ra l he al th se rv ic es , a nd si nc e th is c on ce pt is fu nd am en ta l t o th e su cc es s o f t ub er cu lo si s c on tro l in d ev el op in g co un tri es I sh ou ld li ke to e la bo ra te so m ew ha t o n th is . Th an ks t o a s ys te m at ic re se ar ch p ro gr am m e in a f ew o f th e d ev el op in g c ou nt rie s w e ha ve , w e ha ve a s ea rli er m en tio ne d, t oo ls th at h av e be en s im pl ifi ed a nd s ta nd ar di ze d to t he p oi nt w he re m ul ti- pu rp os e h ea lth w or ke rs , af te r so m e w ee ks o f tra in in g, c an di ag no se a nd t re at i nf ec tio us t ub er cu lo si s a t th e c os t of a f ew d ol la rs a c as e a nd im m un iz e th e su sc ep tib le p op ul at io n a t th e c os t of a f ew c en ts p er v ac ci na tio n. A ll de ve lo pi ng c ou nt rie s a re , an d w ill i nc re as in gl y b e, e ng ag ed i n a m aj or p ub lic h ea lth str ug gl e to p ro vi de ba sic , co m pr eh en siv e c om m un ity he al th s er vi ce s in ur ba n, an d pa rti cu la rly i n ru ra l, ar ea s, T he r ea so n fo r th is i s no t on ly t he a cu te s ho rta ge o f he al th pe rs on ne l a nd f un ds , b ut al so th at ru ra l p eo pl e a re in cr ea sin gl y r es ist in g t he ne ve r- ce as in g ru sh o f s ho rt- liv ed s pe ci al c am pa ig ns l ea vi ng t he m w ith ou t a p er - m an en t po in t of r ef er en ce f or t he ir d ay -to -d ay h ea lth p ro bl em s. A ll, c om m un ic ab le 81 H . M AH LE R di se as e ca m pa ig ns h av e ov er w he lm in gl y de m on st ra te d th at o nl y th ro ug h fa lli ng b ac k on str on g ba sic h ea lth s er vi ce s in d ev el op in g co un tri es is it p os sib le to a ch ie ve a n ef fe ct iv e co ns ol id at io n of th es e ca m pa ig ns . T he in te gr at ed tu be rc ul os is p ro gr am m e, th ou gh s lo w in its u pt ak e, w ill g ro w o rg an ic al ly to ge th er w ith th e he al th s er vi ce s, ea ch s tre ng th en in g th e ot he r b y ad di ng to th e co nf id en ce th ey in sp ire in th e pu bl ic . In th e fe w c ou nt rie s t ha t h av e st ar te d to p ut in te gr at io n se rio us ly in to p ra ct ic e th e re w ar d ha s fa r su rp as se d ex pe ct at io ns . W ith in o ne to tw o ye ar s fro m th e be gi nn in g of in te gr at ed op er at io ns it w as p os sib le to e ne rg iz e th e ge ne ra l h ea lth se rv ic es to su ch a n ex te nt th at m or e th an h al f o f t he to ta l l oa d of in fe ct io us tu be rc ul os is w as b ei ng sy ste m at ic al ly d isc ov er ed ; t ha t tre at m en t e ffi ci en cy w as ra ise d fro m a n ap pa lli ng 8 0 pe r c en t d ru g de fa ul t t o m or e th an 6 0 pe r c en t c om pl et in g on e fu ll ye ar o f t re at m en t; an d va cc in at io n co ve ra ge in cr ea se d fro m 2 5 pe r c en t t o m or e th an 7 0 pe r c en t o f a ll el ig ib le s. Le t m e em ph as iz e on ce m or e: i nt eg ra tio n is no t sy no ny m ou s w ith a l ai ss ez -fa ire ap pr oa ch . O n th e co nt ra ry ,i t r eq ui re s m ax im um in vo lv em en t o f a ll sp ec ia liz ed p er so nn el as p ro gr am m er s, or ga ni ze rs , t ut or s, an d as se ss or s, bu t n ot a s a lo of p er fe ct io ni st s. I sh ou ld l ik e to e nd m y co m m en ts by e m ph as iz in g fo ur c on di tio ns f or i m pl em en tin g ef fe ct iv e na tio na l t ub er cu lo si s p ro gr am m es in d ev el op in g co un tri es to da y. Fi rs tly , th e pr og ra m m e m us t be p la nn ed a nd t he p la n m us t re fle ct t he o pt im al co m pr om is e be tw ee n w ha t i s te ch ni ca lly d es ira bl e fo r th e fe w a nd w ha t i s op er at io na lly fe as ib le fo r t he m an y. T o ac hi ev e t hi s, in di vi du al ex pe rie nc e, in tu iti on an d gu es sw or k m us t b e re pl ac ed w ith a s ys te m at ic a na ly sis o f th e ex ist in g ep id em io lo gi ca l an d so ci o- ec on om ic sit ua tio n su pp le m en te d w he ne ve r ne ce ss ar y w ith ca re fu lly co nd uc te d op er at io na l in ve st ig at io ns . Se co nd ly , t ra in in g an d re -tr ai ni ng o f a ll sp ec ia liz ed a nd m ul ti- pu rp os e he al th p er so nn el is a si ne q ua n on f or t he e ffi ci en cy o f th e pr og ra m m e. T hi s tra in in g m us t pa rti cu la rly b e or ie nt at ed to w ar ds th e or ga ni za tio na l a nd a dm in is tra tiv e a sp ec ts as n o am ou nt o f t ec hn ic al so ph is tic at io n ca n co m pe ns at e fo r o pe ra tio na l d ef ic ie nc ie s. Th ird ly , ev al ua tio n m us t be b ui lt- in a t al l le ve ls to s er ve a s th e co ns ci en ce o f th e pr og ra m m e. T hi s e va lu at io n m us t v er ify th at th e te ch ni ca l a nd o pe ra tio na l c om m itm en ts o f th e pl an a ct ua lly a re m et a nd th at th e qu al ity a nd q ua nt ity o f t he o ut -p ut o f e ac h w or ke r i s sa tis fa ct or y. T he p re re qu is ite f or s uc h a m ea ni ng fu l ev al ua tio n is s tri ct u ni fo rm ity o f te ch ni qu es a nd re co rd s c om bi ne d w ith a n un bi as ed a na ly si s. Fo ur th ly , n o am ou nt o f l ip -s er vi ce to p la nn in g, tr ai ni ng a nd e va lu at io n w ill b rin g ou t t he be ne fit o f d ru gs a nd v ac ci ne to th e re ce iv in g en d w ith ou t a u ni fy in g ce nt ra l d ire ct io n w ith ad eq ua te p ow er s t o en fo rc e an d, w he n ne ce ss ar y, m od ify th e na tio na l p ro gr am m e. 82 81 82