The Effect of Decentralized Services on Multidrug-Resistant Tuberculosis Care in Sub- Saharan Africa: A Systematic Review

Abstract

Background Multidrug-resistant tuberculosis (MDR-TB), which is resistant to rifampicin and isoniazid, is a significant public health concern. MDR-TB care has transitioned from being centralized where inpatient care provided at specialized facilities to being decentralized, where the focus is on outpatient care provided at the community. This review aims to synthesize results of studies on the effect of decentralizing MDR- TB care on the accessibility of services and patient treatment outcomes in sub- Saharan Africa (SSA). Methods A systematic review which synthesized observational studies, interrupted time series and cost analyses from SSA, published between 2011 and 2021 was conducted. Five databases (PubMed, Cochrane library, Global health, Scopus and Global Index Medicus (WHO)) were searched to identify eligible studies. Quality assessment of included studies was conducted using the Effective Public Health Practice Project (EPHPP) tool for observational studies and the CHEERS checklist for cost evaluation studies. Results Twelve studies met the eligibility criteria for inclusion. In SSA, decentralization of MDR-TB care has been suggested to improve utilization and cost of MDR-TB services. The treatment cost has reduced and volume of patients utilizing both diagnostic and treatment services has increased in all countries represented by the studies. Increased successful treatment as well as reduction in patients who are lost to follow up have also been suggested to be outcomes of decentralizing MDR-TB treatment services within SSA. Conclusion In resource limited settings such as those in SSA, studies have suggested that decentralizing MDR-TB services is beneficial as it enables increased utilization of diagnostic and treatment services at lower service delivery costs. High retention into care and treatment success rates are also suggested to be better achieved and maintained when using decentralized approaches than centralized approaches.