Background: Ukraine has a high burden of drug-resistant tuberculosis (DR-TB). Mental health problems, including alcohol use disorder (AUD), are common comorbidities. One in five DR-TB patients has Human Immunodeficiency virus (HIV). As part of health reform, the country is moving from inpatient-care to ambulatory primary care for tuberculosis (TB). In Zhytomyr oblast, Médecins Sans Frontières (MSF) is supporting outpatient care for DR-TB-patients on all-oral short DR-TB-regimens. This study describes the preparedness of ambulatory care facilities in Zhytomyr oblast, Ukraine to provide good quality ambulatory care.
Methods: This is a retrospective analysis of routinely collected program data. Before discharge of every patient from the hospital, MSF teams assess outpatient facilities available using a standardised checklist. The assessment evaluates access, human-resources, availability of medicines, infection control, laboratory and diagnostic services, and psychosocial support.
Results: We visited 68 outpatient facilities in 22 districts between June 2018 and September 2019. Twenty-seven health posts, 24 TB-units, 13 ambulatories, two family doctors and one polyclinic, serving 30% of DR-TB patients in the oblast by September 2019, were included. All facilities provided directly observed treatment, but only seven (10%) provided weekend-services. All facilities had at least one medical staff member, but TB-training was insufficient and mostly limited to TB-doctors. TB-medicines and storage space were available in all facilities, but only five (8%) stored ancillary medicines. HIV-patients had to visit a separate facility to access HIV-care. Personal protective equipment for infection control was unavailable in 32 (55%) facilities. Basic laboratory services were available in TB-units, but only 4 (17%) performed audiometry. Only ten (42%) TB-units had psychosocial support available, and nine (38%) psychiatric support.
Conclusion: Outpatient facilities in Zhytomyr oblast are not yet prepared to provide comprehensive care for DR-TB patients. Capacity of all facilities needs strengthening with TB-training, infection control measures and infrastructure. Integration of psychosocial services, treatment of co-morbidities and adverse events at the same facility are essential for successful decentralisation. The health reform is an opportunity to establish quality, patient-centred care.