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Free Content A health systems assessment of the KwaZulu-Natal tuberculosis programme in the context of increasing drug resistance

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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.

Keywords: MDR-TB; South Africa; TB programme; operational research; systematic assessment

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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  • The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research. The IJTLD is dedicated to the continuing education of physicians and health personnel and the dissemination of information on tuberculosis and lung health world-wide.

    Certain IJTLD articles are selected for translation into French, Spanish, Chinese or Russian. They are available on the Union website

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