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Worldwide, TB case-finding is not expanding as quickly as is needed to meet 2005 targets, according to the World Health Organization’s 6th annual report on global TB control. In fact, only three countries — India, the Philippines, and Myanmar — managed to ramp up case-finding activities to an appreciable degree in the year 2000, says Christopher Dye, D. Phil, coordinator of the WHO’s TB monitoring and evaluation group. Sometimes, all it took was getting one particular problem straightened out and then harnessing the requisite amount of political will to solid technical direction, Dye says.
In India, for example, the start of progress seems to date back to a point about five years ago, says Dye. "At that point they had a multiplicity of problems. But once they were able to ensure a steady drug supply, a World Bank loan was put into place, and strong technical support was provided by a number of agencies," he says. All those changes sparked a palpable rise in political will, "and things really began to take off."
In the Philippines, the TB scene began looking up in 1996, the year the country did a national prevalence survey. "That provided a clear picture of the problem," Dye explains. "Since then, a strong coalition of partners came together, and they’re doing a very good job."
In Myanmar, the strong centralized government appears to be having a favorable impact on TB control, whatever its faults from a human-rights perspective, Dye says. The same factor of strong central control plays into Vietnam’s success as well, he adds. Vietnam was the only high-burden country that met its goals for case-finding and treatment success for the year 2000, the WHO report notes.
Although Ethiopia and South Africa also posted substantial increases in case-finding, the increases there may not be truly good news, Dye says. "There, the increase may well be due to a real rise in cases due to HIV," he says. "South Africa especially is at a critical point. Our best assessment is that South Africa will see a huge increase in cases over the next few years as a result of the spread of AIDS, and that will be disastrous for the TB program."
The good news is that for about 30 cents per person per year, rich countries could wipe out the funding shortfall for TB programs in the 22 nations most heavily burdened with TB, Dye says. That would plug a $300 million hole that’s keeping the high-burden countries from expanding directly observed therapy-short course (DOTS), he adds. "As I see it, that gap should be fairly easy to fill," he says. What’s less certain, he concedes, is whether closing the gap will actually mean the high-burden countries can meet targets for the year 2005, which consist of finding 70% of TB cases and successfully treating 85% of the cases found.
What will happen, for example, in countries where much TB treatment is still carried out by the private sector? And in countries where the health systems are in a state of virtual collapse, how much weight can a DOTS program actually be expected to bear? "There are some aspects of scaling up — like developing a large-scale private-public mix — about which we simply don’t know enough yet to estimate costs," Dye adds.
Still, just having detailed budgets in hand is a big step forward, Dye contends. "For the first time, we’ve got a really clear definition of the funding problem," he notes.