We engaged 18 participants (10 TB focal persons, four DTLS, and four DTFPs) but interviewed 11 (four DTLS, four DLFPs, and 10 TBFPs) to reach saturation. The mean age of the interviewed participants was 33.6 years (standard deviation, 4.78) and ranged from 27 to 34 years. Majority of the participants were males, and had worked for at least five years. The participants’ characteristics are summarized in Table 1.
Table 1: Participant socio-demographic characteristics
Characteristics
|
Level
|
Frequency (%)
|
Type of respondent
|
District TB and Leprosy Supervisor
|
3 (27.3)
|
|
Laboratory focal person
|
2 (18.2)
|
|
TB focal person
|
6 (54.5)
|
Respondent cadre
|
Clinical officer
|
4 (36.4)
|
|
Laboratory technician
|
2 (18.2)
|
|
Nursing officer
|
5 (45.4)
|
Sex
|
Female
|
3 (27.3)
|
|
Male
|
8 (72.7)
|
Age category (years)
|
≤30
|
2 (18.2)
|
|
>30
|
9 (81.8)
|
|
Mean (SD)
|
33.6±4.78
|
|
Range
|
27-34
|
District of respondent
|
Kumi
|
2 (18.2)
|
|
Ngora
|
3 (27.3)
|
|
Serere
|
2 (18.2)
|
|
Soroti
|
4 (36.4)
|
Work experience (years)
|
<5
|
3 (27.3)
|
|
≥5
|
8 (72.7)
|
|
Mean (SD)
|
4.82±1.40
|
|
Range
|
2-7 years
|
Themes
The emerging themes were categorized as facilitators of or barriers to treatment success. Themes that improved rates of treatment success were designated as facilitators while those that reduced the rate of treatment success were considered as barriers. Table 2 presents a summary of themes that emerged.
Table 2: Emerging themes
Facilitators of treatment success rate
|
- Use of data to make decisions and design interventions
|
- Continuous quality improvement
|
|
|
Barriers to treatment success rate
|
- Lack of motivated and dedicated TB focal persons
|
- Scarce and at times no funding for TB activities
|
- Poor implementation of community-based DOTS
|
Facilitators of treatment success rate
The facilitators of treatment success included the following themes: 1) Use of data to make decisions and design interventions; 2) Continuous quality improvement; 3) Capacity building; and 4) TB as a priority disease.
Use of data to make decisions and design interventions
Participants indicated that all district TB units have performance targets usually set at the beginning of the year. The targets are sub-divided per quarter, month, week, and day to ease tracking and at the end of each reporting time frame, data are collected, analyzed, and the performance for each health facility is tracked. Heath facility based and district TB review meetings are held to share the performance.
Participants agreed that the use of data to monitor and evaluate the performance of the TB performance improved rates of treatment success in the districts.
"During general staff meetings and sometimes end of monthly meetings we review our performance" (KI, Female, 40 years, High TSR district)).
"The key thing we are doing is target setting per health facility because we give health facilities targets which we want them to achieve. Although some achieve and others do not for some reasons but the targets helps us a lot. Because you must do something when you know that this is what I must achieve. I give them [TB focal persons] targets per quarter, per month, and per week so that we can work on that" (KI, Male, 43 years, High TSR district)).
"If a health facility does not achieve the quarterly targets, the balance is carried forward to the next quarter. After the end of the year, we tell the health facilities that you have fallen short of these numbers, but you have to look for this numbers in the next financial year" (KI, Male, 43 years, High TSR district).
"For example Serere HC [Health Center] IV, what we do, we have the TB Focal Persons with whom I share the findings of the health facility TB performance" (KI, Male, 43 years, High TSR district).
Conversely, the participants mentioned that non-use of data to guide decision making has inevitably resulted into low rates of treatment success across TB units in districts with low rates of treatment success.
"We do analyze TB data at the end of the quarter; but there has not been any platform for sharing the performance with health facilities. Because we have got nothing to do with district reviews, where we invite the DHTs and the health facilities to come and then we share TB performance, and where they can be given a chance to explain why they have performed poorly. That is why we have performed just like that [meaning low TSR] because there are no reviews" (KI, Male, 37 years, Low TSR district).
Continuous quality improvement
Participants acknowledged performance gaps in TB care are common in general, which are identified through regular data reviews and addressed by continuous quality improvement (CQI) projects. Some of the notable CQI projects were those that aimed at improving completion of sputum smear monitoring among TB patients.
"Our data people collect the TB registers and they tell us our gaps. We then take actions such as starting a project [meaning quality improvement projects]" (KI, Male, 43 years, High TSR district)
"Actually, the issue of sputum follow-ups has been a big challenge. So I actually started a project [meaning QI projects] on sputum smear follow-ups and that’s why it has come up a little bit" (KI, Female, 28 years, High TSR district)
Capacity building
Participants reported that regular supervisions to TB focal persons have improved the rates of treatment success in the district. They indicated that the supervisions were conducted on quarterly basis by either the DTLS or members of the District Health Team.
"At the district level, the DHO [District Health Officer] gives me a vote for technical support supervision although it is little money about 150,000 (One hundred fifty thousand Ugandan Shillings) every quarter. That means 50,000 [shillings] every month. That means I am able to fuel my motorcycle, go to those underperforming health facilities" (KI, Male, 43 years, High TSR district).
"They [District Health Team members] regularly come around for technical support supervision, especially the District TB and Leprosy Supervisor" (KI, Female, 28 years, High TSR district).
In addition, participants stated there are targeted technical support supervisions carried alongside the regular technical support supervisions at poorly performing TB units in the district. The aim of this was to ensure performance at such health facilities match to those already performing well and hence improve the overall rate of treatment success in the district.
"We [District Health Team] do quarterly support supervision to health facilities. Besides, we identify and support [meaning targeted technical support supervision] those health facilities which are performing badly" (KI, Male, 31 years, High TSR district).
TB as a priority disease
Participants indicated that maximizing treatment completion and sputum smear microscopy monitoring while minimizing loss of TB patients across TB units in the district are the mainstay priority areas for improved rates of treatment success.
"We are concentrating on treatment completion for now. Most of our TB patients actually complete treatment but the problem is sputum follow-ups. Our cure rate is still low although treatment success rate is high" (KI, Female, 28 years, High TSR district).
"All TB patients are monitored by sputum smears and encouraged to take their medications. Those who do not, we follow them up and make phone calls" (KI, Female, 32 years, High TSR district).
Another priority mentioned relates to use of Village Health Team (VHTs), which was a common practice in districts with high rates of treatment success.
"Another thing which is helping us is the use of VHTs [Village Health Team members] especially when TASO [The AIDS Support Organization] supports us we do. We use the VHTs to support us in looking for the lost TB patients so that the patient is brought to care to complete treatment" (KI, Female, 28 years, High TSR district)).
"We use VHTs [Village Health Team Members] as our Ambassadors. In most cases, we ask the client to tell us which VHT is near him/her then the person will give use the names. On the other hand, when we meet with VHTs especially when they come to the ART [Anti-Retroviral Therapy] clinic, we attach them to the client nearer them so that they remind them to come for refills and also follow-up" (KI, Male, 43 years, High TSR district).
However, in districts with low rates of treatment success, participants stated that the use of VHTs was less-commonly practiced.
“We used VHTs at times for tracking TB patients and other things, but of course, you just have to rely on someone’s commitment or willingness which is a personal thing. You do not have control over them” (KI, Male, 34 years, Low TSR district).
In addition, participants stated that unlike in the past years, presently TB patients are accorded priority, provided services as fast as possible, and receive maximum attention from healthcare providers. Second, healthcare providers nowadays have positive attitudes towards TB patients and TB care in general. These reasons were strongly emphasized to have influenced improved rates of treatment success in the districts.
"TB is now like respected; we appreciate that someone has TB and we do not treat them like before where TB was taken like a disease for people who are not hygienic, and where they kept blaming them. When they come for drugs they are given a priority, when they are coughing they are supported" (KI, Female, 32 years, High TSR district).
"Our health facility is not like other places [health facilities] where TB is like a neglected disease; we try to concentrate" (KI, Female, 32 years, High TSR district).
Barriers to treatment success rate
We identified three themes as barriers to treatment success: 1) Lack of motivated and dedicated TB focal persons; 2) scarce and at times no funding for TB activities; and, 3) poor implementation of community-based DOTS (CB-DOTS).
Lack of motivated and dedicated TB focal persons
Participants indicted that the lack of motivated and dedicated TB focal persons has contributed to low rates of treatment success in the districts. They firmly stressed that TB focal persons are inactive partly because most have not received orientation on their assigned roles and responsibilities.
"TB focal persons are not active. Actually, they are not! Most of the TB focal persons right from the time they were told you are the TB focal person, they have never had any orientation. It is just an on job thing where they tell you to monitor this and that….. But the trainings are not there" (KI, Male, 34 years, Low TSR district).
One reasons cited for the lack of motivated and dedicated TB focal persons was the absence of monetary rewards system for good performance. Participants judged existing approaches for rewarding TB focal persons as not useful at all.
"When you perform well they only give you mere handclaps at the meeting. How useful is this?" (KI, Male, 33 years, Low TSR district).
Scarce and at times no funding for implementing TB activities
The lack of funds for implementing TB activities was a general problem in the region reported by participants, and was believed to have impacted negatively on the implementation of TB activities at both community and health facility levels. It was mentioned that in certain instances, limited funds for TB-HIV collaborative activities are provided through implementing partners. However, the downside of this funding was that the money was narrowed to HIV activities and was often submitted late to the health facilities. This resulted into TB focal persons using their own money to pay for transport charges incurred in the follow-up of TB patients.
"At the district level, I basically rely on Implementing Partners only but from the DHT [District Health Team], there is nothing [meaning no funding] allocated to TB” (KI, Male, 34 years, Low TSR district).
"They [implementing partner] actually told us to first use the few resources we have thus to use personal money for transport to the patient's homes for follow up. After, you have to submit the report and then your money is refunded. But as I speak, we are not funded for doing TB outreach and follow ups. (KI, Male, 33 years, Low TSR district).
"The money you put in is refunded by TASO [The AIDS Support Organization], but only after you have submitted a report on the visits conducted. It is challenging because sometimes you don’t have the money readily available on you" (KI, Male, 32 years, Low TSR district).
Poor implementation of community-based DOTS (CB-DOTS)
Community-based DOTS, an important WHO strategy for improving treatment adherence among TB patients was reported to be weak, non-functional, paper-based and impractical. Participants noted that these faults in the implementation of CB-DOTS have resulted into low treatment success.
"You know the other bit is the functionality of CB-DOTs [Community-Based Directly Observed Therapy Short Course] is not there. Many times you will find it is on paper but not actual, according to the way the thing [DOTS] is formulated. It [DOTS] required that the healthcare worker visits the home of the TB patient, does the sensitization, and then selects someone to oversee the swallowing" (KI, Male, 34 years, Low TSR district).