Academic journal article Bulletin of the World Health Organization

Local Problems, Local Solutions: Improving Tuberculosis Control at the District Level in Malawi

Academic journal article Bulletin of the World Health Organization

Local Problems, Local Solutions: Improving Tuberculosis Control at the District Level in Malawi

Article excerpt

Voir page 116 le resume en francais. En la pagina 116 figura un resumen en espanol.


Much has been written about the WHO strategy of directly observed therapy, short-course (DOTS), which has been promoted in the control of tuberculosis (TB) (1). Indeed, great strides have been made recently in introducing the strategy worldwide (2). However, by the end of 1998, 68% of the world's population remained uncovered by this strategy for TB control (2). Doubts have been expressed whether DOTS alone is the answer in TB control, and a more holistic approach has been advocated (3). A recent South African randomized controlled trial (4) showed no significant increase in cure rates among patients receiving directly observed therapy (DOT). The findings of the last-mentioned study are controversial, and concerns about the validity of the findings have been outlined elsewhere (5-7). Controversy notwithstanding, it is worthwhile examining the elements of successful district TB control programmes in developing countries where DOT is not in place.

The hypothesis tested was that if well implemented, the DOTS strategy could achieve high cure rates at the district level, even in the presence of a high prevalence of seropositivity for human immunodeficiency virus (HIV). The objective of the present study was thus to examine the reasons for the low cure rate in a peripheral district of a TB control programme in a resource-poor, high-prevalence country in sub-Saharan Africa. The problems that were identified by cohort analysis of sputum smear-positive pulmonary TB patients are presented, the local solutions that were put into place outlined, and their effects demonstrated. It is argued that the method is applicable to other settings where resources are scarce, but where goodwill among those working in TB control at the district level is abundant.

Study setting


Malawi is a small, landlocked country in Central Africa with a population of about 10 million. It is also one of the poorest countries in the world, with a gross domestic product (GDP) of less than US$ 200 per capita. The country has been hard hit by the dual epidemics of HIV and TB. Over 30% of antenatal women in urban areas are HIV-positive (8). Since 1985, Malawi has operated an International Union against Tuberculosis and Lung Diseases (IUATLD) model TB control programme. Nevertheless, smear-positive pulmonary TB notification rates doubled between 1985 and 1993 (9). Most of this increased caseload was probably due to the rapid spread of the HIV epidemic in the corresponding period, as has been documented elsewhere in sub-Saharan Africa (10, 11).

The Malawi national tuberculosis control programme

The Malawi national tuberculosis control programme (NTP) has a similar administrative structure to other government departments and is supported by IUATLD and foreign donors. The government of Malawi is politically committed to the programme and provides an annual budgetary allocation of funds to the Ministry of Health (MOH). The central TB unit coordinates the programme at a national level, and three regional TB officers have key roles in evaluating the programme. District TB officers are responsible for registration and case holding as well as coordination with other programmes, especially primary health care. Nongovernmental organization (NGO) hospitals and health centres contribute significantly to health care in Malawi, operating outside the formal government structure to deliver 35% of all health care services. Some NGO hospitals participate as treatment centres within the NTP, follow NTP guidelines for diagnosis and treatment of TB patients, and fulfil their recording and reporting requirements.


Mzuzu is the administrative centre of the northern region of Malawi, has a population of 60 000, and is located 360 km north of the nearest tertiary referral hospital in the capital, Lilongwe. …

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