Elsevier

The Lancet

Volume 359, Issue 9308, 2 March 2002, Pages 775-780
The Lancet

Review
Evolution of WHO policies for tuberculosis control, 1948–2001

https://doi.org/10.1016/S0140-6736(02)07880-7Get rights and content

Summary

We examine the evolution of WHO managerial policies for tuberculosis control during 1948–2001 to provide a new framework that will accelerate control expansion in the near future. In the first period (1948–63), a vertical approach to tuberculosis control was the policy adopted by WHO and the international community. However, although this approach was successful in more-developed countries, it largely failed in resource-poor settings. As a result, involvement of general health services was soon deemed essential. During 1989–98, a new framework for effective tuberculosis control was created and a new five-element strategy was branded with the name of DOTS. This period was characterised by the recognition of tuberculosis control as a public-health priority, the intensification of tuberculosis control efforts worldwide, and the return of tuberculosis to the political agenda of governments. However, although nominal adoption of DOTS increased rapidly due to massive promotion by WHO and partners, expansion to provide full access was too slow and only 23% of all infectious cases in 1999 were managed under DOTS. A truly multisectoral approach based on advocacy and social mobilisation, community involvement, and engagement of private-for-profit practitioners is becoming the way forward for tuberculosis control. HIV-associated tuberculosis and multidrug-resistant tuberculosis must be tackled as priority issues. We conclude that, based on the lessons of the past, the future of tuberculosis control should be focused on a pragmatic approach combining a specialised, well-defined management system with a fully integrated service delivery. A multisectoral approach that builds on global and national partnerships is the key to future tuberculosis control.

Section snippets

The vertical programme (1948–63)

After the Second World War, the discovery of effective chemotherapeutic agents against communicable diseases of public health importance (eg, tuberculosis, leprosy, syphilis, yaws) and insecticides against vectors transmitting infectious diseases (malaria, yellow fever, plague) prompted the building of vertical control programmes, also known as categorical or specialised programmes. Each of these programmes established its own structure staffed with specialised personnel from a central level

Integration of service delivery (1964–76)

The first wave of integration was mainly promoted by tuberculosis experts with a long scientific and programmatic experience in less-developed countries. Madras Chemotherapy Centre indicated the efficacy of home treatment and suggested that tuberculosis hospital beds were no longer necessary to cure the disease. The team also highlighted the efficacy of intermittent regimens, which facilitated the full supervision of isoniazid intake as the companion drug of streptomycin injection, given twice

Integration of managerial functions (1977–88)

The second wave of integration was driven by general public-health experts and primary health care promoters. They set aside managers' reluctance to give up their traditional functions in training, supervision, logistics, and communication. Tuberculosis specialists were confined to providing technical guidance to general health managers. The rationale behind these changes was that, because all programmes operated through the same type of managerial and support activities, integration would make

Return to a specialised managerial approach (1989–98)

The result of the philosophical changes in the guiding concepts of the management of health services and programmes had a staggering effect on tuberculosis control during the 1980s. In 1989, the WHO Headquarters staff devoted to tuberculosis had shrunk to two professionals managing a tiny budget for operations. In most WHO Regional Offices, tuberculosis activities were one of the many responsibilities of a general epidemiologist, and no permanent consultants were posted at country level. The

The resurgence of the integrated approaches (1999–2000)

While the cooperation agencies (mostly governmental agencies) and the ministries of health were planning the expansion of the control programmes after the London Declaration, by the end of 1998 WHO was reorganised. This led to the closure of the Global TB Programme at WHO headquarters. The guiding concept for this decision was to integrate the managerial functions of WHO's separate control programmes. The staff working on tuberculosis were incorporated into various new teams organised to

Post-modern tuberculosis control

The post-modern era began with the creation of a partnership aimed at promoting tuberculosis control as an element for health-system development, a basic human right, and an integral part of poverty alleviation strategies. Thus, the StopTB partnership is working in such a way that governments of endemic countries receive, where needed, the adequate support to fulfil their commitments to tuberculosis control. National organisations and institutions, both public and private, have been enlisted

Conclusions

The history of the managerial policies for tuberculosis control shows that the vertical approaches of the early days did not succeed in less-developed countries. It also shows that the integration waves of the 1970s and 1980s have produced mixed results. However, the experience of the past decade, when tuberculosis control again became a special priority at WHO and elsewhere, suggests that without a wider alliance encompassing public and private sectors, public health academic institutions, and

Search strategy and selection criteria

To document the historical evolution of WHO policies assessed in this paper, a thorough review of WHO documents was done. The search focused particularly on policy publications, such as those of the WHO Expert Committees on Tuberculosis, and other published documents available in the official list of WHO documents. We did a Medline search addressing tuberculosis policy to ensure that relevant papers were identified and analysed. We searched for articles under keywords “Tuberculosis”, “Control”,

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