Important note: Information in this article was accurate in 2009. The state of the art may have changed since the publication date.
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Integrated Regional Information Networks - October 29, 2009
Directly observed treatment short course (DOTS), has been used to successfully deliver tuberculosis treatment in some of the world's poorest countries.
The main elements of DOTS include political commitment, case detection, standardized treatment with supervision and patient support, an effective drug supply and management system, and a monitoring and evaluation system.
"The key to rapid and massive scale-up [in Malawi] was to keep the principles and practices of ART delivery as simple as possible," said the authors of an article on scaling up antiretroviral therapy, in the latest edition of the Journal of Acquired Immune Deficiency Syndromes.
Solid systems
"A standardized system was put in place so that the same system of assessing patients for ART eligibility, initiating treatment, and registering and reporting cases and outcomes was followed wherever ART was being delivered - from central hospital to health centre, and from public health facility to private clinic," the authors said.
Malawi began its national ART rollout in 2004 with just nine health facilities providing the medication to about 3,000 people. Using the DOTS framework, by the end of 2008, 170 health facilities in the public health sector had registered 215,449 patients.
A study published in 2008 in the British medical journal, The Lancet, found that rapid scale-up of free ART in rural Malawi had led to a decline in adult mortality that was detectable at the population level.
The article's authors attribute the success of Malawi's ART scale-up to government commitment and leadership; clear national ART guidelines, with emphasis on the system of registration, monitoring and recording of results; intensive training of clinical officers and nurses in ART guidelines, with practical experience at ART sites; an efficient drug-supply chain to prevent stock-outs.
Taking DOTS further
They note that with the rise in prevalence - even in resource-poor sub-Saharan Africa - of non-communicable diseases such as heart attacks, strokes, cancers, diabetes and respiratory diseases, there is a need to put in place simple yet effective systems to give people access to treatment.
The World Health Organization (WHO) forecasts that deaths from non-communicable diseases are likely to increase by 17 percent globally over the next 10 years, with the greatest increase projected in Africa.
"Although patients with these non-communicable diseases usually need chronic care and treatment over their lifetimes, it is simply not provided in most resource-poor countries, outside a few centres of excellence, and there are no systems to monitor patient access or outcomes," they stated.
"The system put in place in Malawi to facilitate the management and monitoring of lifelong ART can also be used for patients with non-communicable diseases."
If handled properly, HIV and chronic disease management systems could be used to strengthen health systems in resource-poor nations, particularly by improving laboratory infrastructure and service delivery, monitoring, supervision, quality assurance, and rational drug forecasting and procurement.
"Any attempt to better the management and monitoring of special diseases must include a vision of how the work will improve the health sector and health care delivery as a whole," they said.
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