A health systems assessment of the KwaZulu-Natal tuberculosis programme in the context of increasing drug resistance
Abstract:SETTING: High mortality and high transmission rates of extensively drug-resistant tuberculosis (XDR-TB) in KwaZulu-Natal Province of South Africa have highlighted the role of hospitals in the spread of TB and drug-resistant TB.
OBJECTIVES: To determine the operational effectiveness of the National TB Programme (NTP) at a regional/district hospital and its referral clinics.
DESIGN: In this multi-faceted retrospective case study, a framework was developed to evaluate the different components of the TB services, their performance in relation to each other and the system as a whole. Different methods used included structured and semi-structured interviews, retrospective medical record reviews and retrospective register reviews.
RESULTS: Only 18% of those diagnosed with smear-positive pulmonary TB (PTB) in the hospital laboratory completed their treatment and 11% were cured. Clinicians did not adhere to the diagnostic guidelines of the NTP. In the TB register, 85% of PTB cases were diagnosed in the absence of sputum microscopy. Chest X-rays alone were used to diagnose PTB in 45% of the records reviewed. In addition, clinicians failed to document a clinical history suggestive of TB. Only 66 (29%) of the hospital’s 225 smear-positive PTB patients reached the clinics for completion of their treatment.
CONCLUSION: System failures, together with inadequate knowledge and understanding of clinicians, undermined the effectiveness of the NTP. A reduction in TB and drug-resistant forms of TB is dependent on effective diagnosis, treatment and improved communication systems between the hospital, laboratory and its down-referral clinics.
Document Type: Regular Paper
Affiliations: 1: Medical Research Council, Tygerberg, South Africa; and Health Systems Trust, Durban, South Africa 2: KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa 3: Medical Research Council, Tygerberg, South Africa 4: Health Systems Trust, Durban, South Africa
Publication date: September 1, 2008
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