title: DOTS implementation in a middle-income country: development and evaluation of a novel approach.
abstract: BACKGROUND
  DOTS is widely accepted as the most cost-effective strategy for tuberculosis (TB) control. However, there is little published information regarding methods for implementation in middle-income countries.
  
  
  METHODS
  Over 3 years, the Canadian Lung Association assisted the Ecuadorian TB programme to implement DOTS for over half the nation's total population. A multilevel strategy developed by a team of Ecuadorian health professionals provided initial, in-service, replica and reinforcement training at the local level, and training at national level for specialist physicians, specialist societies and medical schools. Evaluation was based on international guidelines for case finding, treatment and laboratory quality control, and costs of all implementation activities.
  
  
  RESULTS
  By January 2004, DOTS training had been provided to 1954 health professionals and 199 smear microscopy technicians, and DOTS was implemented in all 496 health facilities. Case detection activities at the local level increased substantially. Cure and treatment completion improved to 83% of new cases. Overall concordance of laboratory quality control readings was 98.7%. The total cost of DOTS implementation was US dollar 3 049 585.
  
  
  CONCLUSIONS
  To achieve international targets for TB control, DOTS implementation in a middle-income country required intensive training at the local level and at multiple other levels.
authors.affiliation: Canada-Ecuador Technical Cooperation to Strengthen the National Tuberculosis Programme in Ecuador, Quito.
authors.forename: J
authors.initials: J
authors.lastname: Vaca
authors.forename: H
authors.initials: H
authors.lastname: Peralta
authors.forename: L
authors.initials: L
authors.lastname: Gresely
authors.forename: R
authors.initials: R
authors.lastname: Cordova
authors.forename: D
authors.initials: D
authors.lastname: Kuffo
authors.forename: E
authors.initials: E
authors.lastname: Romero
authors.forename: T N
authors.initials: TN
authors.lastname: Tannenbaum
authors.forename: S
authors.initials: S
authors.lastname: Houston
authors.forename: B
authors.initials: B
authors.lastname: Graham
authors.forename: L
authors.initials: L
authors.lastname: Hernandez
authors.forename: D
authors.initials: D
authors.lastname: Menzies
mesh_terms: D023801:Directly Observed Therapy / Q000191:economics; D004484:Ecuador / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007318:Inservice Training; D016730:Program Development; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*