Responding to Health System Failure on Tuberculosis in Southern Africa

Abstract

The characteristics of tuberculosis (TB)-such as links to poverty, importance of patient actions, and prevalence of multisectoral drivers-require more from health systems than traditional medically oriented interventions. To combat TB successfully, health systems must also address social risk factors and behavior change in a multisector response. In this, many health systems are failing. To explore why, and how they can do better, we apply the Flagship Framework and its five "control knobs" (financing, payment, organization, regulation, and behavior) to the literature on TB control programs, focusing on the mining population of Southern Africa, among whom the incidence of TB is highest in the world. We conclude by recommending a patientcentered approach that broadens a system's engagement to a wholeof-health sector, whole-of-government response.

Through service providers’ eyes: health systems factors affecting implementation of tuberculosis control in Enugu State, South-Eastern Nigeria

“…Although TB service providers have used electronic reminders to improve treatment adherence similar to China's experience [17], weak patient tracking systems resulted from poor funding and lack of transportation. Notwithstanding existence of guidelines for TB/HIV integration, weak TB/HIV collaboration is similar to evidence from other studies [10,12,14,24,28]. Policies to improve TB service delivery system must address stigma among health workers, strengthen laboratory capacity, incentives to community volunteers and patent medicines vendors, improve funding of patient tracking and bolster TB/HIV integration.…”

“…Whereas stewardship from the NTP improved district TB service delivery, stewardship from local government (LG) was weak despite existence of memorandum of understanding between LGs and NTP. Effective bureaucratic relationship between state and LG TB programmes in this study contradicts evidence of poor stewardship in India, Ghana and South Africa [7,12,24]. In our setting, accountability relationship was enhanced by programme management support, supportive supervision and quarterly performance review meetings.…”

“…Constraints to TB control include perception that TB control is less important than other public health programs [20,23]; weak accountability relationship between provincial/regional and district TB programme management [7,12,24]; insufficient community involvement [25]; and low public spending on TB [5][6][7][9][10][11][12][13]. TB control have been limited by lack of skilled staff [4,10,11,19,22]; lack of incentives for service providers [4,5,10]; lack of utilization of various levels of health staff and health facilities [25]; poor attitude and weak commitment of health workers towards deployment to TB services [22,23], inadequate training [10,11,19], and lack of laboratory staff [5,22,23].…”

“…Poor adherence to GeneXpert algorithm, interrupted supply of cartridges, lack of replacement of damaged modules, poor maintenance, and poor recording and reporting limit usefulness of GeneXpert in TB diagnosis [14,26,27]. Poor adherence to national guidelines [11,22,23]; dilapidated infrastructure [5,12,23] weak TB/HIV integration [10,12,14,24,28]; lack of public-private mix [10,12,23] and poor integration into general health services hinder effective TB service delivery [5,29,30].…”

Collaborative Governance in Implementation National Health Insurance Program in Bandung City

“…Collaboration between stakeholders has not been optimal, there is still a lot of obscurity in the data request process. These findings also occur in other developing countries, such as tuberculosis programs in South Africa that are fragmented due to different health systems between levels (Hartel, Yazbeck, &Osewe, 2018). Collaboration between stakeholders is difficult due to the fragmentation of national, regional, and health systems.…”