Evolution of WHO policies for tuberculosis control, 1948-2001.

We examine the evolution of WHO managerial policies for tuberculosis control during 1948-2001 to provide a new framework that will accelerate control expansion in the near future. In the first period (1948-63), a vertical approach to tuberculosis control was the policy adopted by WHO and the international community. However, although this approach was successful in more-developed countries, it largely failed in resource-poor settings. As a result, involvement of general health services was soon deemed essential. During 1989-98, a new framework for effective tuberculosis control was created and a new five-element strategy was branded with the name of DOTS. This period was characterised by the recognition of tuberculosis control as a public-health priority, the intensification of tuberculosis control efforts worldwide, and the return of tuberculosis to the political agenda of governments. However, although nominal adoption of DOTS increased rapidly due to massive promotion by WHO and partners, expansion to provide full access was too slow and only 23% of all infectious cases in 1999 were managed under DOTS. A truly multisectoral approach based on advocacy and social mobilisation, community involvement, and engagement of private-for-profit practitioners is becoming the way forward for tuberculosis control. HIV-associated tuberculosis and multidrug-resistant tuberculosis must be tackled as priority issues. We conclude that, based on the lessons of the past, the future of tuberculosis control should be focused on a pragmatic approach combining a specialised, well-defined management system with a fully integrated service delivery. A multisectoral approach that builds on global and national partnerships is the key to future tuberculosis control.