• M Khan Ibrahim
  • Samreen Khan
  • Ulrich Laaser


Background: Despite the fact that Directly Observed Treatment Strategy (DOTS) short course is cost effective and universally recommended by WHO for effective TB control, it is beyond the financial reach of several highly endemic countries. This article aims at identifying barriers in DOTS’s implementation and progress in 22 high burden countries (HBCs) from TB. Methods: Medline abstracts, published papers and WHO reports were retrieved, critically examined and compared keeping standard parameters of TB control in view. Results & Conclusion: The increasing caseload, morbidity and mortality due to TB in high burden countries have become a major health challenge and threat to the health systems. The escalated burden of disease and deaths due to TB has posed a great threat to the international security. In the last decade little progress has been witnessed in the implementation of WHO’s recommended strategy called DOTS in the 22 high burden countries. Afghanistan, Pakistan, India, Brazil, Zimbabwe, S. Africa and Uganda are some of the countries still facing challenges in the effective introduction, implementation and expansion of DOTS. Financial inabilities contribute greatly to the failure of respective national TB control programs. High burden countries are usually in the economic recession or passing through severe socio-political turmoil that has further reduced spending on TB control. Majority depends on the international assistance and put little domestic efforts. Coupled with the lack of political commitment to the issue of TB control, authors urge high TB control Program managers in HBCs to increase spending and pay a great deal of commitment to the universal implementation of DOTS, increase case detection and case management to attain their global targets. Key words: DOTS, TB control, high burden countries.


ICMR Bulletin. Directly observed treatment short-course: tuberculosis cure for all vol.31, No.3 (ISSN 0377-4910) March, 2001).

Research for Action: Understanding and Controlling Tuberculosis in India. World Health Organization, Regional Office for Southeast Asia, New Delhi, 2000.

Global DOTS Expansion Plan: Progress in the TB control in high burden countries. One year after the Amsterdam ministerial conference. WHO Publication. Geneva, Switzerland. 2001.

Amsterdam Declaration to Stop TB.


Netto EM, Dye C, Raviglione MC. Progress in global tuberculosis control 1995-1996, with emphasis on 22 high-incidence countries. Global Monitoring and Surveillance Project. Int J Tuberc Lung 1999; 3[4]:310-20.

Stop TB Initiative, WHO Country profile, 1997-98 Annual Reports.

Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA 1999; 18; 282(7):677-86.

Raviglione MC, Harries AD, Msiska R, Wilkinson D, Nunn P. Tuberculosis and HIV: current status in Africa. AIDS 1997; 11 (suppl): S115-23.

Gustafson P, Gomes VF. Tuberculosis mortality during a civil war in Guinea-Bissau. JAMA 2001; 286(5): 1:599-603.

Spinaci S, De Virgilio G. Tuberculin survey among Afghan refugee children. Tuberculosis control program among Afghan refugees in North West Frontier Province [NWFP] Pakistan. Tubercle 1989;70(2):83-92.

Ahmad K. Stop TB Partnership to Focus on Afghanistan and Pakistan. Lancet 2001;358:9291:1431.

World Health Organization. Fifty-third World Health Assembly. Stop Tuberculosis Initiative, Report by the Director-General. A53/5, 5 May 2000; Resolution WHA53.1.

Dye C, Scheeles S, Dolin P, Pathania V, Raviglione MC. Global burden of tuberculosis: Estimated incidence, prevalence, and mortality by country. JAMA1999; 282, 677-686. (

World Health Organization. World health report 2000: health systems: improving performance. WHO. Geneva (

Ahlburg D. The Economic Impacts of Tuberculosis. The Stop TB Initiative 2000 series. WHO/CDS/STB/2000.5 Geneva. (

World Health Report 2000, Assessment of world’s health system performance. WHO.

Tuberculosis and Sustainable Development: the Stop TB Initiative 2000 Report. Geneva, World Health Organization. (

World Health Organization. Global Tuberculosis Control. WHO Report 2001. WHO/CDS/TB72001.287 ( publications/globrep01/index.html).

Suarez PG, Watt CJ, Espinal MA, Dye C. The dynamics of tuberculosis in response to 10 years of intensive control effort in Peru. J Infect Dis 2001; 184(4):473-8.

Bosman MC. Health sector reform and tuberculosis control: the case of Zambia. Int J Tuberc Lung Dis. 2000;4(7):606-14.

Visschedijk J. A fresh look at the health for all. Medicus Tropicus 1997; 35 (Suppl):6.

WHO. Health for all in the 21st century. 1997 Draft policy-PPE/PAC/97.5. Geneva.

Smith I. Tuberculosis global economy, global injustice. 2000-Stop TB initiatives, WHO.