In reply to Ian Harper\'s letter (#250), we wish to bring to the notice of readers that there is evidence and research produced by the National Tuberculosis Program (NTP) to support conclusions in Naresh Newar\'s article (TB or not TB, #248). We would like to respond to the three central comments of Ian Harper\'s letter. First, the NTP has presented strong empirical evidence (from individual patient data) that during the last few years the program has grown in conflict affected mid-western districts at least as fast as in the rest of the country. So far the program has had minimal difficulties operating and expanding in conflict affected areas although the conflict is throwing up logistical challenges, and we need, and are preparing for an ever more challenging context. We appreciate Ian Harper\'s argument that the operating context requires quality monitoring, which NTP will endeavour to provide whilst remaining confident with the evidence and analysis provided to date. Ian Harper\'s assertion that \'many health posts are closed or are understaffed as a consequence of the current conflict\' is probably true-but the evidence of this (that Ian Harper would agree is needed) is small scale and largely anecdotal. A deeper appreciation of the conflict\'s impact on health service functioning is needed.

Second, Ian Harper writes about \'a truly prolific growth of TB control in the private sector\'. There is evidence that suggests the contrary. Research carried out recently in Lalitpur by the NTP and Nuffield, Leeds University, suggests that where the TB program is working well, the private sector treatment of tuberculosis diminishes rapidly and TB drugs become much less available in private pharmacies. The NTP is notable, in relation to other areas of the national health program, for its active engagement with the private sector. A mature, and ever-growing, partnership is established resulting in the private sector partners adhering to NTP\'s diagnostic and treatment protocols.

Third, DOTS (Directly Observed Treatment strategy piloted in Nepal in the 1990s) has proved to produce better cure rates than the unsupervised model. The current NTP patient cure rates of over 85 percent suggest that this has been the right strategy to follow. Finally, claims about the relative success of the NTP come from international TB experts who have frequently visited the NTP during the last few years. The NTP is satisfied with their verdict and is willing to share more information with interested professionals.

KB Shrestha, NTP Program Director
Susan Clapham, Health Adviser, DfID
Christian Gunneberg, WHO Nepal