DOTS Expansion and Enhancement

High-quality Directly Observed Treatment, Short-Course (DOTS) has proven to be a very effective and affordable approach for controlling TB and is especially valuable in resource-poor settings. If implemented appropriately, DOTS has been shown to have an average success rate (cure and completion of treatment) of 80 percent and can also help prevent the emergence and spread of drug-resistant TB. Implementing DOTS appropriately requires political commitment with increased and sustained financing. Those investments support case detection through quality-assured bacteriology, standardized treatment, supervision and patient support; a functional system to procure, deliver, and manage a dependable supply of high quality TB drugs; and an effective monitoring and surveillance system that also measures impact.

USAID gives priority to increasing routine screening and testing for TB and the initiation of treatment for persons who are confirmed to have active TB. Quality improvement measures ensure adherence to treatment standards, improve cure and treatment completion rates, and increase capacity for pharmaceutical management. Efforts are expanded to ensure that women are appropriately reached and that gender considerations are integrated into all DOTS programs. Infection control measures implemented in health facilities reduce the risk of disease transmission among patients as well as laboratory workers and health providers. Funding to the Global TB Drug Facility (GDF) supports grants to purchase TB drugs to countries in need. USAID improves monitoring and evaluation of TB control activities, the quality of data, and the analysis and use of routine information to improve program performance. Surveillance activities assess epidemiological trends and measure the impact of programs.

USAID focuses the majority of its technical and financial resources in countries that have the greatest burden of TB. Selection criteria for priority countries include:

• High burden  of TB cases (among the list of 22 high-burden countries)
• High burden or prevalence of drug-resistant TB
• High incidence of TB (estimated incidence rates of over 100/100,000)
• High HIV/AIDS prevalence (TB-HIV co-infection)
• Lagging case detection and treatment success rates

Political commitment, technical, financial need, and managerial feasibility are also considerations. USAID supports TB programs in more than 40 country and regional programs, with the following countries as priorities:

• Tier 1 Countries: Afghanistan, Bangladesh, Brazil, Cambodia, Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Mozambique, Nigeria, Pakistan, the Philippines, Russia, South Africa, Tanzania, Uganda, Ukraine, Zambia, and Zimbabwe.
• Tier 2 Countries: Angola, Armenia, Azerbaijan, Belarus, Bolivia, Djibouti, Dominican Republic, Georgia, Ghana, Haiti, Kazakhstan, Kyrgyzstan, Malawi, Mexico, Namibia, Peru, Senegal, Southern Sudan, Tajikistan, Turkmenistan, and Uzbekistan.

Monitoring and Evaluation

USAID is expanding and strengthening the monitoring and evaluation system for tuberculosis programs by adopting a coherent and strategic system. This enables USAID to routinely measure progress toward goals at the global, national and project level. As USAID investments in tuberculosis increase, the Agency must find effective and efficient ways to collect quality data and use the data to make programmatic decisions.

The purpose of the monitoring and evaluation system is to:

• Measure progress
• Improve accountability and management of resources
• Efficiently and effectively use data
• Improve coordination with partners
• Collect complete and timely information on USAID's contribution to the global effort to control tuberculosis

USAID supports the World Health Organization (WHO) Global TB Monitoring and Surveillance project, as a key investment in providing information on the global, regional, and country level TB program and epidemiological situation. Through WHO, USAID also supports monitoring of progress toward the Millennium Development Goals (MDGs) for TB. The Agency plays a key role in the development and standardization of monitoring and evaluation instruments through a global working group led by WHO. Existing tools are evaluated and adapted, and new tools will be developed to assist USAID missions and TB program managers in the use of effective benchmarks for measuring progress and evaluating TB activities throughout the lifecycle of their programs.

The U.S. Government submits an annual report to Congress that describes the results and impact of U.S. foreign assistance on efforts to control TB as required by the Reauthorization Act. Our monitoring includes impact indicators that are reported annually as well as other forms of oversight on  program quality and  challenges in scaling-up. The following key indicators are reported for  countries with established USGTB programs:

• Progress toward the Stop TB goals of reducing TB deaths and disease burden by 50 percent compared to the 1990 baseline;
• The number of tuberculosis cases diagnosed and the number of cases cured in countries receiving U.S. bilateral foreign assistance for tuberculosis control purposes;
• Case detection and treatment success rates in new sputum smear-positive TB patients under DOTS programs;
• The number of new sputum smear-positive TB patients successfully treated under DOTS programs; and
• The number of persons who have been diagnosed and started treatment for MDR-TB in countries receiving U.S. bilateral foreign assistance for tuberculosis control programs.

The Annual Report also includes other required information about USG programs, including:

• A description of activities supported with U.S. tuberculosis resources in each country and how these activities contribute to increasing the number of people diagnosed and treated for TB;
• The percentage of the total U.S. assistance provided for direct TB services in each country receiving bilateral foreign assistance for TB control purposes;
• A description of research efforts to combat TB, including new diagnostics, drugs and vaccines supported by U.S. bilateral assistance;
• A description of collaboration and coordination of the USG with the WHO, the Global Fund and other major public and private entities;
• Constraints on implementation of programs posed by health workforce shortages and capacities;
• The number of people trained in TB laboratory diagnosis, treatment and control;
• A breakdown of expenditures for direct patient TB services, drugs and other commodities, drug management, training in diagnosis and treatment, health systems strengthening, research and support costs;
• A discussion of efforts to strengthen health systems as part of TB control; and
• A description of areas where there has been successful integration of TB control programs with other global health programs (HIV, maternal and child health, etc.) as part of the GHI.