Analysis of a success story: Implementation of DOTS strategy in China

We took a closer look at one of the case studies from Millions Saved - following references to make sure that the account given by the primary sources matched the picture given by the case study. The case study we examined was Case 3: Controlling Tuberculosis in China.

What was done?
Did it work?
What did it cost?
Sources

What was done?

The World Bank and the World Health Organization1 provided funding and technical assistance in China to significantly expand its tuberculosis control program:2

The project aimed in twelve provinces, covering about half of China's population, to expand and improve free provision of tuberculosis diagnostic services; free provision of anti-tuberculosis chemotherapy to reduce the sources of infection; and to improve case management by the adoption of a revised standard tuberculosis registry, reporting forms and supervisory protocol. The project also aimed at institutional strengthening through: the establishment of a National Tuberculosis Project Office and Tuberculosis Control Center; reorganizing and upgrading provincial tuberculosis control programs; implementing a tuberculosis policy package of administrative, technical and financial reforms to improve the systems by which the TB dispensaries in participating provinces are financed and managed; and operational research on management, economic, social and epidemiological factors to improve tuberculosis control and the preparation of future health programs. Initially, these activities were to be carried out from 1992 to 1998.

Note that the Levine (2007) writeup claims 13 provinces, not 12,3 which may be the due to the fact that one of the 12 provinces split in 1996.4

Did it work?

Data collection: China conducted randomized national surveys of TB prevalence in both 1990 and 2000.5

Analysis: A study by the China Tuberculosis Control Collaboration (2004) used regression analysis to compare provinces with DOTS to provinces without DOTS. It used regression analysis to attempt to control for a variety of differences in these provinces not related to changes brought about by the program.6 The dissent (more about this below) summarizes the finding of this study:7

The estimated prevalence of pulmonary tuberculosis, in the 13 provinces in which the DOTS programme was implemented with support from the World Bank, was 573 per 100 000 population in 1990, and fell to 298 per 100 000 population in 2000; a reduction of 48% (95% CI 35—61). In the remaining 15 provinces, which were not supported by the World Bank (the municipalities of Beijing, Shanghai, and Tianjin were excluded from the analysis), the prevalence fell from 493 per 100 000 to 412 per 100 000; a reduction of 16% (1—35). On the face of it, DOTS brought about a 30% greater fall in tuberculosis prevalence than would have occurred had DOTS not been implemented.

Dissent and possible alternative explanations: A comment on the study by the China Tuberculosis Control Collaboration (2004) notes that the 1990 and 2000 surveys were different in many ways, including smaller sample size for the 2000 survey, thus making the comparison less than ideal. It also observes,8

Implementation of tuberculosis control in the DOTS provinces was dependent, in part, on those provinces being able to mobilise counterpart funding to complement funding by the World Bank. Provinces that were either better resourced or better organised at the outset will have been more able to implement effective tuberculosis control. Better organisation, leadership, and economic power of provincial administrations could, therefore, have contributed significantly by providing the foundations for a strong health system, well able to deliver the DOTS strategy. General economic development can also be expected to lead to a reduction in tuberculosis transmission as a result of better living conditions and improved access to health services.

Its observation of the available data shows that the DOTS provinces were indeed higher-income, although not dramatically so:9

In 1990, the average gross domestic product was 1525 yuan per head in the 13 DOTS provinces, compared with 1298 yuan per head in the 15 non-DOTS provinces. By 2000, average gross domestic product had risen to 4156 yuan per head in DOTS areas compared with 3655 yuan in non-DOTS areas. The percentage of the population living in poverty was 9% in the DOTS provinces compared with 13% in the non-DOTS provinces, in 1991.

Despite these reservations, the authors conclude,10

So, should we dismiss DOTS? Indeed we should not. Dye and colleagues' paper gives strong support to expanded implementation of the strategy, both in China and worldwide. It is important, however, that wider implementation comes with careful and critical appraisal of what is needed to make DOTS work.

Bottom line: The impact demonstration didn't have the rigor of a randomized controlled trial, but such an expectation would be unreasonable for a "macro" story such as this one. The evidence is fairly compelling and Levine's (2007) conclusion about this program's impact is, on the whole, reasonable.

What did it cost?

$130 million, roughly half of which was covered by the government and half of which was covered by a grant from the IDA arm of the World Bank.11

This matches the figure in the Levine (2007) case study.12

Sources

Chen, Xianyi, et al. 2002. The DOTS strategy in China: Results and lessons after 10 years (PDF). Bulletin of the World Health Organization 80(6):430-436.
Levine, Ruth. 2007. Case 3: Controlling tuberculosis in China (PDF). In Case studies in global health: Millions saved. Sudbury, MA: Jones and Bartlett.
China Tuberculosis Control Collaboration. 2004. The effect of tuberculosis control in China. Lancet 364(9432):417-422. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)16764-0/fulltext#article_upsell (free registration required; accessed July 14, 2009). Archived by WebCite® at http://www.webcitation.org/5uYku5mws.
Squire, S. Bertel, and Shenglan Tang. 2004. How much of China's success in tuberculosis control is really due to DOTS? Lancet 364(9432):391-392. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)16777-9/fulltext?_eventId=login#bib1 (free registration required; accessed July 14, 2009). Archived by WebCite® at http://www.webcitation.org/5uYl0TBj1.
The third nationwide random survey for the epidemiology of tuberculosis in 1990. 1992. Zhonghua Jie He He Hu Xi Za Zhi 15(2):69-71, 125. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1394592 (accessed July, 14 2009). Archived by WebCite® at http://www.webcitation.org/5uYlAkoyI.
World Bank. 2002. China - Infectious and endemic disease control project: Implementation completion and results report (PDF). Washington, DC: World Bank.

1
"The Bank was the only financier of the project but development, implementation, and supervision of the project would also require effective cooperation with the World Health Organization (WHO)." World Bank 2002, Pg 3.
2
World Bank 2002, Pg 4.
3
Levine 2007, Pg 1.
4
China Tuberculosis Control Collaboration 2004 claims 13, citing Chen 2002, Pg 2, which says "In 1996, Sichuan province split off a municipality called Chongqing. Thereafter, there were 12 provinces and one municipality in the project. To simplify the presentation of data, however, we have reported project results using the old undivided province of Sichuan."
5
- See "The third nationwide random survey for the epidemiology of tuberculosis in 1990" 1992 for 1990 study. China Tuberculosis Control Collaboration 2004, Pg 422, Reference 8 also cites the 1990 study but we haven't found it online.
- "Diagnosis" section of China Tuberculosis Control Collaboration 2004, Pg 418 describes the medical methods of assessing TB.
- "The 1990 survey used stratified random sampling as in 2000." China Tuberculosis Control Collaboration 2004, Pg 419.
6
"In multivariate regression, we fitted a separate model for each year, with age (in 5-year classes), sex, urbanisation, region, and project included as categorical variables, together with terms for the interactions between project and sex, project and urbanisation, and project and region." China Tuberculosis Control Collaboration 2004.
7
Squire and Tang 2004, Pg 391.
8
Squire and Tang 2004, Pg 391.
9
Squire and Tang 2004, Pg 391.
10
Squire and Tang 2004, Pg 392.
11
"The total project cost at appraisal was US$271 million equivalent. This was to be financed by an IDA credit of SDR 95.9 million, equal at the time to US$129.6 million. The provincial governments were to contribute US$139.2 million equivalent to financing the provincial components of the project. The central government was to finance US$2.2 million equivalent for the central component. The final total project cost of US$264.9 million is 97.7% of the total cost that was estimated at appraisal. This small change in total project cost was due to the exchange rate fluctuation between the SDR and US$ from appraisal to project closing, although 100% of the credit (SDR 95.5 million) was expended. The final financing for the project was US$126.7 million from IDA, US$137.5 million from the provincial governments, and US$0.7 million from the central government. ... The actual expenditure by component was US$129.7 million for TB, compared to US$102.5 million at appraisal, US$139.7 million for schistosomiasis, compared to US$145.4 million at appraisal, and for the central component, US$2.7 million equivalent, compared to US$4 million equivalent at appraisal. As noted earlier, much of the increased expenditure on TB was used for improving case detection and management, and was financed largely by savings on the cost of drugs. Those savings stemmed from the reduced need for drugs to the delayed start up of TB efforts, rapid decline in endemicity of schistosomiasis, and much lower than expected cost of drugs that were procured domestically." World Bank 2002, Pgs 12-13.
12
"The total cost amounted to nearly $130 million in the end." Levine 2007, Pg 6.