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


OBJECTIVE
To determine the operational effectiveness of the National TB Programme (NTP) at a regional/district hospital and its referral clinics.


METHODS
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.


CONCLUSIONS
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.
Loveday
M
M
Medical Research Council, Tygerberg, South Africa. marian.loveday@mrc.ac.za
Thomson
L
L
Chopra
M
M
Ndlela
Z
Z
D000995:Antitubercular Agents / Q000627:therapeutic use; D003695:Delivery of Health Care / Q000458:organization & administration*; D054908:Extensively Drug-Resistant Tuberculosis / Q000175:diagnosis / Q000188:drug therapy*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008499:Medical Records; D009313:National Health Programs / Q000458:organization & administration*; D009874:Operations Research; D010352:Patient Dropouts; D012017:Referral and Consultation / Q000458:organization & administration* / Q000706:statistics & numerical data; D012042:Registries; D012189:Retrospective Studies; D013019:South Africa; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000188:drug therapy
D000995:Antitubercular Agents