IMPROVING TB DIAGNOSIS: PERFORMANCE EVALUATION OF THE TB CARE MEDICAL SPECIMEN TRANSPORT SYSTEM IN ZIMBABWE DECEMBER 2014 This publication was produced at the request of the United States Agency for International Development (USAID). It was prepared independently by Social Impact, Inc. Cover photo: TB CARE Specimen Transport System courier, riding from laboratory to clinic Photo credit: D. Roumis, 2014 - ii - IMPROVING TB DIAGNOSIS: PERFORMANCE EVALUATION OF THE TB CARE MEDICAL SPECIMEN TRANSPORT SYSTEM IN ZIMBABWE This publication was produced at the request of the United States Agency for International Development (USAID). It was prepared independently by Danae Roumis, Samuel Clark, Reuben Musarandega, Roy Mutandwa, Reggie Mutetwa, and Tinashe Sande, on behalf of Social Impact, Inc. Contact: Social Impact, Inc. 2300 Clarendon Blvd., Suite 1000 Arlington, VA 22201 Danae Roumis: [email protected] December 2014 Performance Evaluation: Task Order No. AID-613-M-14-00004 TB CARE ST system: Cooperative Agreement No. AID-OAA-A-10-00020 Suggested Citation: Roumis D, Clark S, Musarandega R, Mutandwa R, Mutetwa R, Sande T. Improving TB Diagnosis: Performance Evaluation of the TB CARE Medical Specimen Transport System in Zimbabwe. USAID Evaluation, December 2014. DISCLAIMER: The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. - iii - CONTENTS EXECUTIVE SUMMARY.............................................................................................................. x 1. INTRODUCTION AND BACKGROUND ............................................................................. 1 Context ........................................................................................................................................................................... 1 TB CARE Program in Zimbabwe .............................................................................................................................. 1 Medical Specimen Transport System ........................................................................................................................ 1 Evaluation Purpose & Audience ................................................................................................................................. 3 Evaluation Questions .................................................................................................................................................... 3 2. METHODOLOGY .................................................................................................................... 4 Overview ......................................................................................................................................................................... 4 Qualitative Data ............................................................................................................................................................. 4 Quantitative Data .......................................................................................................................................................... 5 Data Analysis .................................................................................................................................................................. 5 Strengths and Limitations ............................................................................................................................................ 7 3. FINDINGS ................................................................................................................................. 8 Implementation .............................................................................................................................................................. 8 Effectiveness ................................................................................................................................................................. 15 Access ....................................................................................................................................................................... 16 Timeliness ................................................................................................................................................................. 24 Treatment ................................................................................................................................................................ 26 Contextual Factors ................................................................................................................................................ 30 Integration ..................................................................................................................................................................... 33 Sustainability ................................................................................................................................................................. 36 Non-Program Districts .............................................................................................................................................. 38 4. CONCLUSIONS ..................................................................................................................... 40 5. RECOMMENDATIONS ......................................................................................................... 41 References .................................................................................................................................... 46 Appendices ................................................................................................................................... 49 Appendix 1: Detailed Methodology ........................................................................................................................ 50 Appendix 2: Data Appendix ..................................................................................................................................... 54 Appendix 3: Recommended Follow-on Research ............................................................................................... 67 - iv - TABLES & FIGURES TABLES TABLE 1. DISTRICTS IN ZIMBABWE, BY PROGRAM STATUS AND START DATE ........................................................... 6 TABLE 2. SUMMARY OF RECOMMENDATIONS ............................................................................................................... 41 TABLE 3. QUALITATIVE DATA COLLECTION SUMMARY .............................................................................................. 53 FIGURES FIGURE 1. GEOGRAPHIC COVERAGE, TB CARE ST SYSTEM IN ZIMBABWE ............................................................... IX FIGURE 2. TB CARE ST SYSTEM SPECIMEN CARRIER BOX ............................................................................................ 2 FIGURE 3. DISTRICT SELECTION AND DATA COLLECTION ............................................................................................ 6 FIGURE 4. MOTORCYCLES AT RFH HEADQUARTERS ..................................................................................................... 8 FIGURE 5. COURIER SAFETY GEAR .................................................................................................................................... 9 FIGURE 6. TB CARE ST SYSTEM COURIER MOTORCYCLE .......................................................................................... 10 FIGURE 7. SPUTUMS COLLECTED & TB RESULTS RETURNED: MAJOR CITIES, SINCE 2010 ....................................... 11 FIGURE 8. SPUTUMS COLLECTED & TB RESULTS RETURNED: OLDER DISTRICTS, SINCE 2012 ................................ 11 FIGURE 9. SUBJECTIVE ASSESSMENT OF THE QUALITY OF ST SYSTEM IMPLEMENTATION ........................................ 12 FIGURE 10. COURIER PACKS CARRIER BOX AND TRAY USING GLOVES SUPPLIED BY CLINICS ................................. 13 FIGURE 11. COURIER MOTORCYCLE WITHOUT ADEQUATE CARRIER BOX ............................................................... 13 FIGURE 12. CARRIER BOXES OF VARYING SIZES ............................................................................................................. 14 FIGURE 13. SUBJECTIVE ASSESSMENT OF ST SYSTEM EFFECTIVENESS .......................................................................... 15 FIGURE 14. COURIER MOTORCYCLE HOUSED AT DISTRICT HOSPITAL ...................................................................... 15 FIGURE 15. SUBJECTIVE ASSESSMENT: CHANGE IN CLINIC SPUTUM COLLECTION .................................................. 17 FIGURE 16. TB SUSPECTS EXAMINED WITH SSM FOR DIAGNOSIS (DISTRICTS), 2008-2014 .................................. 19 FIGURE 17. TB SUSPECTS EXAMINED WITH SSM FOR DIAGNOSIS (PROVINCES), 2008-2014 ................................ 20 FIGURE 18. SUBJECTIVE ASSESSMENT: CHANGE IN TB SMEAR NOT DONE ............................................................... 21 FIGURE 19. CASES OF TB SMEAR NOT DONE (DISTRICTS), 2008-2014 ................................................................... 22 FIGURE 20. CASES OF TB SMEAR NOT DONE (PROVINCES), 2008-2014 ................................................................. 23 FIGURE 21. SUBJECTIVE ASSESSMENT: CHANGE IN LOST TO FOLLOW-UP ................................................................ 27 FIGURE 22. CURE RATE AND TREATMENT COMPLETION RATE (DISTRICTS),