NATIONAL TUBERCULOSIS PROGRAM REVIEW - EXPERIENCE OVER THE PERIOD 1990-95

Since 1990 the WHO Global Tuberculosis Programme (GTB) has promoted th e revision of national tuberculosis programmes to strengthen the focus on directly observed treatment, short-course (DOTS) and close monitor ing of treatment outcomes. GTB has encouraged in-depth evaluation of a ctivities through a comprehensive programme review. Over the period 19 90-95, WHO supported 12 such programme reviews. The criteria for selec tion were as follows: large population (Bangladesh, Brazil. China, Eth iopia, India, Indonesia, Mexico, and Thailand); good prospects of deve loping a model programme for a region (Nepal, Zimbabwe); or at advance d stage of implementation of a model programme for a region (Guinea, P eru). The estimated combined incidence of smear-positive pulmonary tub erculosis was 82 per 100 000 population, about 43% of the global incid ence. The prevalence of infection with human immunodeficiency virus (H IV) was variable, being very high in Ethiopia and Zimbabwe, but neglig ible in Bangladesh, China, Nepal and Peru. The programme reviews were conducted by teams of 15-35 experts representing a wide range of natio nal and external institutions. After a 2-3-month preparatory period, t he conduct of the review usually lasted 2-3 weeks, including a first p hase of meetings with authorities and review of documents, a second ph ase for field visits, and a third phase of discussion of findings and recommendations. The main lessons learned from the programme reviews w ere as follows: programme review is a useful tool to secure government commitment, reorient the tuberculosis control policies and replan the activities on solid grounds; the involvement of public health and aca demic institutions, cooperating agencies, and nongovernmental organiza tions secured a broad support to the new policies; programme success i s linked to a centralized direction which supports a decentralized imp lementation through the primary health care services; monitoring and e valuation of case management functions well if it is based on the righ t classification of cases and quarterly reports on cohorts of patients ; a comprehensive programme review should include teaching about tuber culosis in medical, nursing, and laboratory workers' schools; good qua lity diagnosis and treatment are the essential requirements for expand ing a programme beyond the pilot testing; and control targets cannot b e achieved if private and social security patients are left outside th e programme scope. The methodology of comprehensive programme review s hould be recommended to all countries which require programme reorient ation; it is also appropriate for carrying out evaluations at 4-5-year intervals in countries that are implementing the correct tuberculosis control policies.