We approached 18 participants (10 TB focal persons, four DTLS, and four DTFPs) but reached saturation after 11 interviews (three DTLS, two DLFPs, and six TBFPs). Of the participants interviewed, six (two DTLS, three TBFPs, one DLFP) were from districts with lower level of TSR while five (one DTLS, three TBFPs, one DTLFP) were from districts with higher level of TSR. The mean age of the participants interviewed 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 more than five years. Table 1 presents a summary of the participants’ characteristics.
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)
|
Participant distribution
|
District with low level of TSR
|
6 (54.5)
|
|
District with high level of TSR
|
5 (45.5)
|
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
Themes that were reported by respondents in districts with high treatment success were grouped as facilitators of treatment success while those in districts with low treatment success were classified as barriers to treatment success presented in Table 2.
Table 2: Emerging themes
Themes
|
Sub-themes
|
Facilitators of treatment success rate
|
· Use of data to make decisions and design interventions
|
|
· Continuous quality improvement
|
|
· Capacity building
|
|
· Prioritization of better management of people with TB
|
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) Prioritization of better management of people with TB.
Use of data to make decisions and design interventions
Participants indicated that all the district TB units have performance targets that are usually set at the beginning of the year. To ease performance tracking and reporting, the targets are sub-divided on quarterly, monthly, weekly, and daily basis. At the end of each reporting time frame, data are collected and analyzed, and the performance for each health facility is tracked. To ensure data driven decision making, heath facility and district based TB review meetings are held so that health facility specific performances are shared and actions developed for each identified gap. The participants agreed that the usage of data in monitoring and evaluating the performance of the TB program has improved the rates of treatment success in the districts.
"During general staff meetings and sometimes end of monthly meetings we review our performance" (KI, 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, 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, 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, High TSR district).
On the other hand, participants reported that non-use of data to guide decision is associated 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, Low TSR district).
Continuous quality improvement (CQI)
CQI involves applying appropriate methods to close gaps between current and expected level of quality or performance as defined by standards. The aim is to systematically improve service quality by addressing gaps between current practices and desired standards. The Ministry of Health, Uganda requires all health facilities to have CQI teams constituted from existing staff members from each department and a community representative headed by the In-charge of the health facility or any member deemed fit. The role of the team is to address gaps in quality of health services provided to patients. At some health facilities, QI teams have been formed and are functional. However, at other health facilities, the CQI teams are either non-existent, non-functional, or existent but non-functional. Participants mentioned that performance gaps in TB care are common, and these are identified through regular data reviews but are addressed through the initiation of CQI projects. Some of the notable CQI projects were those that aimed at improving completion of sputum smear monitoring among people with TB.
"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, 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, High TSR district)
Capacity building
Building the competence of healthcare providers is important in delivery of quality services to people with TB. Notable capacity building opportunities include onsite mentorships, technical support supervisions, coaching, and offsite trainings. In this study, participants reported that regular supervisions to TB focal persons have helped to improve the capacity of TB focal persons in providing better care to people with TB hence the improved the rates of treatment success in the districts. According to the participants, supervisions were conducted on quarterly basis by either the DTLS or members of the District Health Team during which TB focal persons are coached in a one-to-one session on the diagnosis and treatment of TB, and how to monitor response to TB treatment as well how to record and compile TB data. The purpose is to improve the knowledge and competence of TB focal persons in providing quality services to people with TB. The TB focal persons gain more skills through practical interaction with their senior visiting colleagues.
"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, High TSR district).
"They [District Health Team members] regularly come around for technical support supervision, especially the District TB and Leprosy Supervisor" (KI, High TSR district).
In addition, participants stated that targeted technical support supervisions were conducted alongside the regular technical support supervisions at poorly performing TB units in the district. The aim was to improve performance at poorly performing health facilities so as to match that of already well performing health facilities. These kinds of approaches were viewed to have associated with high rate of treatment success.
"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, High TSR district).
Prioritization of better management of people with TB
This theme highlights an attitudinal shift to patient-centered approach in caring for people with TB. In districts with high treatment success rate, participants stated that in the past years, people with TB were not given priority by healthcare providers, but this had now changed because they receive services before other patients. Second, healthcare providers have positive attitudes towards people with TB and TB care in general. These reasons were emphasized to be associated with high 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, 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, High TSR district).
Participants indicated that maximizing treatment completion and sputum smear microscopy monitoring while minimizing loss of people with TB across TB units in the district are the main 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, 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, 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, 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, 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, Low 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). In the subsequent paragraph, we discussed these themes into details.
Lack of motivated and dedicated TB focal persons
The provision of TB services at health facility level to people with TB is by a TB focal person, an individual appointed by the head of the health facility. Such appointments are neither salaried nor receive special allowances but are added responsibilities. Participants reported that TB focal persons lack motivation and dedication in providing care to people with TB. This was viewed to have associated with 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, Low TSR district).
One reason mentioned by participants for lack of motivated and dedicated TB focal persons was the absence of monetary rewards for good performance. Participants judged existing approaches for rewarding TB focal persons as not being useful at all.
"When you perform well they only give you mere handclaps at the meeting. How useful is this?" (KI, 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. This was reported by most participants to be associated with low rate of treatment success in the districts. It was mentioned that in certain occasions, limited funds for TB-HIV collaborative activities are provided, mostly by implementing partners. However, the funds are restricted to implementing HIV activities only. In addition, the funds are often submitted late to respective health facilities and this has resulted into TB focal persons using their own money in paying for transport charges incurred in the follow-up of people with TB.
"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, 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, 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, Low TSR district).
Poor implementation of CB-DOTS
CB-DOTS, one of the five components of the WHO DOTS strategy for improving treatment adherence among people with TB was reported to be weak, non-functional, paper-based, and impractical. It was noted by most of the participants that the faults in the implementation of CB-DOTS is associated with low rate of treatment success in the districts.
"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, Low TSR district).