Missed opportunities? Coercion or commitment: policies of prevention.

The DOTS strategy (directly observed therapy, short course) has been the cornerstone of international TB control policy since the early 1990s. This strategy has provided the international community with an advocacy tool to harness funds for TB as well as a method for helping country programs to achieve high cure rates for TB. But as much as the strategy is seen as successful by some, it is perceived as unsuccessful by others. This paper looks at the results of the introduction of DOTS into control programs and discusses research relating to direct observation of treatment. It asks how policies like DOTS are created, and how they are administered and transferred from the international to the national and finally to the local level. The discipline of public health policy is used to interrogate the creation and history of the DOTS strategy in order to find ways of aiding the transfer of the policy to national and local levels. Finally, the paper asks whether the concepts of "control" and "elimination" continue to be useful in the management of infectious diseases. We ask whether it is time to change the perspective to policies that focus more on the context of implementation and the importance of the development of care, integration, and flexibility rather than cure, targets, and short-term solutions.