Afghanistan Expands Successful Urban DOTS Program

{Photo credit: MSH staff}Photo credit: MSH staff

Kabul is the largest city in Afghanistan, with a population of over 3 million people. The population density leads to overcrowding and strains health systems and infrastructure. In a country with a high tuberculosis (TB) burden, TB service delivery has been a particular challenge. In 2009, only 22 of the 106 existing public and private health facilities in Kabul provided partial TB services. TB case detection was only 26 percent, and the treatment success rate was 49 percent. All TB indicators for the city consistently fell below national targets.

Directly observed therapy, short course (DOTS) is a World Health Organization (WHO)-recommended strategy for improving TB treatment outcomes and increasing case detection. The guiding principles are political commitment and sustained financing; case detection through quality-assured bacteriology; standardized treatment with supervision and patient support; an effective drug supply and management system; and a monitoring and evaluation system and impact measurement. In 2009, MSH, through the USAID-funded TB CAP project, and staff from Afghanistan’s National TB Program (NTP), conducted a baseline assessment to determine whether an Urban DOTS program would be an effective strategy in Kabul.

The assessment examined treatment outcome data from the 22 existing health facilities that provided partial TB diagnostic and treatment services. It also highlighted the challenges facing the health facilities, including lack of TB for workers, poor supervision, and a weak reporting system. Health facilities also faced a shortage of TB drugs and lab reagents, and many did not have permanent buildings.

Based on findings from the assessment, the NTP and other local partners, with assistance from MSH and TB CAP, decided to engage public and private health facilities to offer Urban DOTS with the aim to reduce morbidity and mortality related to the disease. The effort involved strengthening coordination among multi-sector stakeholders (public, private, and NGOs) and developing a strategic plan. To address logistical and supply challenges, the team engaged members of the private sector who agreed to play a clearly defined role. Health care workers were trained in TB service delivery and the DOTS strategy and facilities received quarterly supervisory visits.

Results of the integrated effort were encouraging and demonstrated that the Urban DOTS program was effective. One of the most important outcomes was the improvement of case detection from 26 percent in 2009 to 60 percent in 2014. Lessons learned were incorporated into the revised strategic plan for the period of 2015 to 2019.


In April 2015, due to the significant achievements of the program, the NTP with the Challenge TB Afghanistan project, led by MSH, agreed to expand Urban DOTS program to other big cities such as Kandahar, Herat, and Jalalabad. The initiative has been hugely welcomed by participants and 165 representatives from a variety of institutions have already trained.

For more information on the Urban DOTS experience and MSH’s work with Challenge TB Afghanistan, please contact Ghulam Qader.