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In India, which accounts for 30% of the global burden of TB, the DOTS programme is undergoing massive expansion as treatment success rates double and death rates fall. Government commitment, community involvement, and partnerships have all been key factors in the success of the DOTS programme in India.

A massive expansion of TB treatment using DOTS is today under way in India. By the end of 2000, one in four of the population -- over 250 million people -- will be covered by the strategy. By the end of 2002, it is planned that half the country will be covered. Eventually, it is hoped that the entire population of over one billion will have access to DOTS.

Up until late 1998, only 2% of the population were covered by DOTS. By early 1999, the number had soared to over 120 million and the numbers have been rising ever since.

The logistics involved in such rapid large-scale expansion were considerable. Over 10 000 doctors had to be trained, 2000 laboratory technicians, and 100 000 allied health workers. An additional 500 staff were employed. Almost 3000 microscopes had to be purchased and enough TB drugs to treat over 400 000 patients. Meanwhile, hundreds of thousands of technical documents had to be finalized and printed. Any future expansion will have to be phased to ensure that drug supplies, training, supervision, and monitoring can all be guaranteed. The stakes are high. India accounts for about 30% of the global burden of TB. An estimated one in two of the adult population are infected with the TB bacterium. Every year, two million people develop active tuberculosis -- more than in any other country in the world. And about 450 000 die from it -- more than the total deaths from AIDS, malaria, and tropical diseases combined.

Launched in 1993 with a series of successful small-scale pilot projects, the DOTS programme has shown continued impressive success rates. A recent analysis of the impact of the programme found that 80% of cases were successfully treated -- twice as many as in the previous TB programme. Death rates among infectious patients treated within the programme were 4%, compared with a rate over seven times higher in the non-DOTS programme.

India's DOTS programme is mainly financed through a US $ 142 million low-interest loan from the World Bank, with an increasing proportion of the costs already being met by the national and state governments. Treatment is supervised by health workers, community volunteers, traditional birth attendants, and community or religious leaders. Community workers supervise treatment for patients with limited access to a health centre. Additional staff are provided to serve difficult mountainous, tribal, and urban areas.

In order to maintain the uninterrupted supply of drugs throughout the treatment period, each patient is allocated an individual box at the outset containing the full course of treatment. This helps ensure that no patient has to stop treatment because drugs are not available, even in the event of a break in the drugs supply chain.

Ironically, India was one of the seedbeds for the global DOTS strategy, but it was many years before the idea took root there. In the 1950s, the Tuberculosis Research Centre in Chennai (formerly Madras) demonstrated that treatment observation is both necessary and feasible in the community, using intermittent treatment. In the early 1960s, India demonstrated that most TB patients did not need to be in hospital. In Madras, even destitute people living on the streets in slum areas were successfully treated with a regular supervised course of TB drugs. Meanwhile, the National Tuberculosis Institute in Bangalore demonstrated that, with minimal training and regular supervision, technicians working at the periphery could carry out sputum smear microscopy -- enabling this to become the primary tool for diagnosis of TB.

Today, as India establishes the second largest DOTS programme in the world (after China), the wheel has turned full circle. But there is still a long way to go before DOTS is available country-wide.

Operation ASHA has been successful in providing tuberculosis treatment to residents of the urban slums in India by locating treatment centers within convenient existing locations where patients would otherwise go, including temples, hair salons and the shops of traditional healers. By hiring counselors from the local population, launching its innovative biometrics fingerprint scanning system, and tying counselors’ pay to performance, Operation ASHA has discovered a model for tuberculosis treatment that – in its pilot areas – has resulted in a default rate of zero.

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