Izudi et al. BMC Health Services Research (2019) 19:979 https://doi.org/10.1186/s12913-019-4834-2 RESEARCH ARTICLE Open Access Explaining the successes and failures of tuberculosis treatment programs; a tale of two regions in rural eastern Uganda Jonathan Izudi* , Imelda. K. Tamwesigire and Francis Bajunirwe Abstract Background: Optimally performing tuberculosis (TB) programs are characterized by treatment success rate (TSR) of at least 90%. In rural eastern Uganda, and elsewhere in sub Saharan Africa, TSR varies considerably across district TB programs and the reasons for the differences are unclear. This study explored factors associated with the low and high TSR across four districts in rural eastern Uganda. Methods: We interviewed District TB and Leprosy Supervisors, Laboratory focal persons, and health facility TB focal persons from four districts in eastern Uganda as key informants. Interviews were audio recorded, transcribed verbatim, and imported into ATLAs.ti where thematic content analysis was performed and results were summarized into themes. Results: The emerging themes were categorized as either facilitators of or barriers to treatment success. The emerging facilitators prevailing in the districts with high rates of treatment success were using data to make decisions and design interventions, continuous quality improvement, capacity building, and prioritization of better management of people with TB. The barriers common in districts with low rates of treatment success included lack of motivated and dedicated TB focal persons, scarce or no funding for implementing TB activities, and a poor implementation of community-based directly observed therapy short course. Conclusion: This study shows that several factors are associated with the differing rates of treatment success in rural eastern Uganda. These factors should be the focus for TB control programs in Uganda and similar settings in order to improve rates of treatment success. Keywords: Barriers, Facilitators, Health systems strengthening, Treatment success, Tuberculosis, Uganda Background centralized and prioritized system of TB monitoring, re- The overall goal of a tuberculosis (TB) control program cording and training; access to quality-assured sputum is to ensure people with TB who are enrolled in the pro- microscopy; standardized short-course chemotherapy for gram complete treatment and become cured, endpoints all cases of TB under proper case management condi- collectively referred to as treatment success. Directly ob- tions, including direct observation of treatment by a served therapy short course (DOTS) is a global strategy healthcare worker or community health worker for at for effective control of TB and its wider application has least the first 2 months; uninterrupted or sustained sup- resulted into better treatment outcomes in several coun- ply of quality-assured drugs; and standardized recording tries [1]. For instance, countries which have imple- and reporting system that allows assessment of treat- mented all the five components of DOTS namely ment have reported high rates of cure and treatment sustained political or government commitment, includ- completion [2]. In particular, the observation of people ing political will at all levels, and establishment of a with TB as they take medication in real time by a treat- ment supporter or a healthcare provider ensures good * Correspondence: [email protected] adherence to and completion of treatment [3]. Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Izudi et al. BMC Health Services Research (2019) 19:979 Page 2 of 10 Although DOTS has been adopted and implemented respectively. The districts were purposively selected to widely, the achievement of the WHO desired treatment provide a framework for comparison of a well versus success rate (TSR) of at least 90% remains a challenge for poorly performing district TB control program. The most TB programs globally. Recent statistics suggest that variation in performance for these TB control programs the global TSR for newly diagnosed bacteriologically con- provides a basis and natural setting for our study. firmed pulmonary TB (BC-PTB) has declined from 86% in Altogether, the population in the four districts, located 2014 to 83% in 2017 [4]. This decline presents an unpre- about 300 km from Kampala Capital City, is close to one cedented concern for TB programs because of exacerba- million people. We enrolled participants from TB units tions in TB morbidity and mortality [5]. In addition, there with the highest patient loads in the selected districts. is significant variation in TSR across sub Saharan Africa, The estimated number of new people with TB in the both between and within countries. The between country study districts were 191 in Serere, 340 in Soroti, 313 in variation is seen from TSR of 83.4% in Cameroon [6], Kumi, and 121 in Ngora for the period July 2017 to June 90.1% in Ethiopia [7], and 75.7% in Nigeria [8]. 2018 [13]. In Soroti district, the units included Soroti Uganda is an example of a country with significant vari- Regional Referral Hospital, Princess Diana Memorial ation in TSR. Overall, the country has a cure rate of 48% Health Center (HC) IV, and Tiriri HC IV. A health cen- and a TSR of 80% [9], which are far below the desired ter IV is a county level health facility in the structure of WHO targets of 85% for cure rate and at least 90% TSR. Uganda’s health system. The study sites in Kumi district In rural eastern Uganda, two districts of Serere and Ngora included Kumi Hospital, Atutur Hospital, and Kumi HC have higher TSR surpassing the WHO desired target of IV. Kumi Hospital is a private not for profit health facil- over 90% while the other two districts of Soroti and Kumi ity. The study sites in Ngora district were Ngora Hos- have at most 70% TSR, falling below the target. To date, pital and Ngora HC IV and in Serere district, Serere and information on factors shaping the variation in TSR across Apapai HC IVs were selected. these districts in the same region is limited. The purpose Each health facility has a TB diagnostic and treatment of this study was therefore to explore factors associated unit which provides TB services according to the WHO with high and low TSR across districts in rural eastern TB treatment guidelines [3]. At each TB unit, there is a Uganda. Exploring these factors is important for designing TB focal person who is either a nursing, clinical, or medical strategies and interventions that may be used to tackle officer to coordinate and provide TB services. However, hindrances to achieving high TSR while the good practices technical leadership for TB management in the entire district identified may be scaled up to improve TSR. is provided by the District TB and Leprosy Supervisor (DTLS), and each district has one. With respect to TB diag- Methods nostic services, each district also has a District Laboratory Study design and participants focal person (DLFP) to provide technical oversight. We conducted a qualitative study and interviewed key in- formants to explore the successes and failures of the TB Data collection and quality control control program in rural eastern Uganda. The study par- Data were collected through audio-recording of key ticipants consisted of health facility TB focal persons informant interviews which were conducted in English (TBFPs), District TB and Leprosy Supervisors (DTLS), language in June 2019 at the selected health facilities. JI (a and District Laboratory focal persons (DLFPs) from both male public health specialist with experience in mixed- settings, districts with low and high TSR. These partici- methods research) introduced the topics for the interview pants were purposively sampled as key informants because to the key informants and conducted the interviews, but they had rich-knowledge and experience in TB program- was assisted by BK (a female social and public health spe- ing and the functioning of the district healthcare system cialist with 10 years of experience in qualitative research) to and hence were expected to provide reliable and credible allow sufficient probing. The interview questions were information [10]. We interviewed these participants until asked in a non-sequential manner as the participant’sre- emerging ideas or responses were not any different from sponses determined the next question to be asked, provided the ones earlier reported, suggesting saturation of ideas all the required topics were responded to at the end of the hence sufficient qualitative data as recommended [11]. interview. All the key informant interviews were conducted in a quiet room and each lasted on average between 30 to Study setting 45 min. The key informant interview guide (Additional file 1) This study was conducted in four predominantly rural was specifically developed for this interview but was districts in eastern Uganda, namely Soroti, Kumi, Ngora, reviewed and approved by relevant research ethics commit- and Serere. Soroti and Kumi districts have recently re- tees, and pre-tested in the neighboring district of Katakwi ported low TSR of 70 and 66.7% [12], while Ngora and to assess its suitability. All participants’ responses were Serere districts have high TSR of 90.9 and 95.3% [12], transcribed within 48 h of completing data collection. Izudi et al. BMC Health Services Research (2019) 19:979 Page 3 of 10 Measurements number: 03/11–18) and the Uganda National Council for We asked the key informants questions on the following: Science and Technology (Reference number: HS 2531).