Towards development of a novel approach for enhancement of TB diagnostic services during the pandemic : a case of primary health care clinics in eThekwini District KwaZulu-Natal

Abstract

Tuberculosis (TB) is an important public health issue in South Africa that has burdened health systems for decades. The past decade has seen progress in the management of this disease. However, the advent of the coronavirus disease 2019 (COVID-19) has disrupted the provision of essential TB services, resulting in TB detection dropping in the early phase of the pandemic. This has subsequently affected TB incidence and mortality. Therefore, in addition to recovery plans, TB services require strengthening to withstand future health crises. As such, this study aimed to generate evidence to inform a novel approach for improving TB diagnostic services in high-burden settings using the eThekwini district in KwaZulu Natal (KZN) Province, South Africa, as a study setting. Methods The study employed a multiphase mixed methods study design consisting of four phases. Initially, a scoping review was conducted to gather the available evidence on TB services during the COVID-19 pandemic. The findings were used to inform the objectives for the rest of the study. During the first phase, a geospatial analysis was conducted to calculate the geographic accessibility of TB diagnostic services at primary healthcare clinics in eThekwini district. The second phase consisted of a quasi-experimental study that determined the impact of COVID-19 on TB diagnostic services. The barriers and facilitators to providing quality diagnostic services were explored for the third phase through a facility audit and patient interviews. In the final phase, a Nominal Group Technique (NGT) was conducted with relevant TB stakeholders to develop an approach for enhancing TB diagnostic services during the pandemic. Together, the study’s findings were synthesized and used to inform a framework to improve and strengthen the quality of TB diagnostic services. Results The scoping review revealed that the COVID-19 pandemic severely impacted TB detection due to various factors, including limited access to facilities. This prompted recommendations that could facilitate better service provision amid the pandemic. The study’s geographic access evaluation determined that diagnostic services were highly accessible to most (92.6%) of the vii eThekwini population. The areas of poor accessibility mainly consisted of the rural population. Moreover, the analysis determined that many TB cases were in urban and sub-urban regions. The study also found that the impact of COVID-19 on TB detection was severe during the lockdown, showing 45% and 40% decreases in TB investigations and confirmed cases, respectively. These indicators recovered when lockdown measures were lifted. However, the peaks of SARS-CoV-2 variant-driven infection resulted in overall decreases in confirmed cases of TB. The assessment of the quality of TB diagnostic services revealed that many IPC aspects and continuous TB training were lacking at facilities, in addition to long turnaround times for GeneXpert results. Patients perceived long wait times, staff attitudes, and drug stockouts as barriers to quality services. Lastly, stakeholders identified key barriers to diagnostic services during the pandemic and developed an approach to overcome them. They suggested integrating TB/COVID-19 activities, continuous training among staff, strengthening IPC, decentralizing TB testing, using Point-of-Care tests (POC) and raising public awareness through social media platforms to enhance diagnostic services. Conclusion The present study has successfully developed a novel approach for enhancing tuberculosis (TB) diagnostic services at Primary Health Clinics (PHCs) in high-burden regions using the eThekwini district as a study setting. The approach involved devising a consolidated framework for providing high-quality diagnostic services, which is informed by the evidence generated in the thesis. The framework provides guidance on improving structural factors such as accessibility, infection prevention and control (IPC), and care processes, including continuous training and service integration. This comprehensive approach has the potential to improve service delivery and boost public confidence in the health system, ultimately leading to better health outcomes.