Introduction

TB is currently the leading cause of morbidity and mortality from an infectious disease and while a lot of progress has been made in the identification and treatment of tuberculosis, the WHO still estimates that about 4 million cases   of TB were missed in 2017. Improving basic standards of TB care can attract more patients by ensuring that they receive the care that they deserve and     that providers offer better services, improve adherence, diagnosis and treatment, and reduce lost to follow-up rate, ultimately contributing to  reducing the burden of TB disease.

Nigeria ranks as one of the high-burden TB countries in the world and contributed 4% of all TB cases in 2017, ranking her in the 6th position globally in terms of percentage contribution.

Catching them early

Standards set by the International Standards for Tuberculosis Care (ISTC) provide a reference point for assessing provider or system performance and quality of care which help to identify the current and expected levels of quality in health care delivery. The failure of providers or systems to adhere to the defined standards of diagnosis, care and treatment of TB compromises the quality of services provided to the patients.

Understanding the quality of care will enable policy makers and program implementers to strengthen TB care and prevention, by positively influencing timely diagnosis, treatment adherence, and treatment completion in Nigeria. This brief presents findings from an examination of the adherence of TB services in Nigeria to the international and national standards guidelines to ensure that TB services are delivered in an accessible, timely, safe, effective, efficient and equitable manner.

Quality of Care; Where? How… And then?

Quality of care can be said to consist of three key elements, namely: structure of the resources available at a health facility; process or the interaction between providers and patients; and outcomes or the consequences of care.

In a recent study carried out by the Academy for Health Development (AHEAD) Nigeria, supported by the National Tuberculosis and Leprosy Control Program and Challenge TB project funded by United States Agency for International Development (USAID) and The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Quality of Care of Tuberculosis was assessed in a total of 144 facilities across 12 states in a bid to understand how care is accessed and received, uncover loopholes and opportunities in the care delivery system and make recommendations for improving the overall access, delivery and outcomes of care and treatment for tuberculosis.

Structure (Where)

Structure includes all of the factors that affect the context or enabling environment in which care is delivered. This includes the physical facility, equipment and human resources as well as organizational characteristics such as staff training and supervision. We measured structure through  the availability of services, infrastructure, capacity of TB providers, and management of TB services.

TB drug supply

The NTBLCP continues to address challenges to the maintenance of an uninterrupted supply of anti-TB drugs by working to improve stock status at the state and LGA levels, train staff on proper anti-TB drug stock management, and advocate at the Federal and State Ministries of Health to improve and expand storage conditions for anti-TB drugs at all levels. TB drug monitoring mechanisms are in place at different levels to ensure an uninterrupted supply of quality-assured anti-TB drugs, which will help prevent the emergence of drug-resistant TB.

Trained TB Care Providers

Staff training is essential for keeping health workers updated with knowledge, skills, and technical competence to maintain high quality or improve the quality of TB care services. This study assessed whether TB providers received any formal or structured in-service training related to the services they offer in the 24 months preceding the survey.  The findings from the facility audit/checklist (with the health facility unit in-charges as respondents) indicate that a majority of staff (73%) received in-service or training updates on TB care and treatment in the last 24 months.

Process (How)

Process is the sum of the interaction between service providers and patients during which structural inputs from the health care system are transformed into health outcomes. Findings presented measured process through the level of TB awareness among TB patients, patient-provider interaction and communication, barriers to TB care and access to follow-up care.

The most common barrier to accessing TB care mentioned by patients is the distance to the facility providing TB diagnosis and treatment (22%). Lack of adherence   to   a   patient’s   treatment   plan   for   TB   can   lead   to   prolonged infectivity, drug resistance and poor treatment outcomes.

Access to follow-up care through Directly Observed Treatment (DOT) seeks to improve adherence to TB treatment by observing patients while they take their anti-TB medication. This study shows that approximately 40% of patients did not have access to DOT.

Patients on treatment who were observed taking their TB medication by a health care provider (DOT)

Outcome (And then)

Outcome in the context of our conceptual framework refers to the effects of health care on patients, including changes in their health status.

Treatment outcome is defined based on the 2013 WHO definitions that have two broad classifications namely; treatment success and unsuccessful treatment  outcomes. In addition, the two classifications are sub-divided into 6 distinct outcomes, namely; cured, treatment completed, died, treatment failure, loss to follow-up, and not evaluated.   The addition of “cured” and “treatment completed’ is defined as treatment success. Patients with PTB with bacteriologically confirmed TB at the beginning of the treatment who had proven negative microbiological results upon completing treatment are defined as cured. Treatment completed is used  for the patients with no evidence of clinical failure, but without the record to show negative microbiological results after taking anti-TB drugs for the prescribed length of time, either because tests were not performed or because no biological material was available (e.g., patient without sputum production). Patients with treatment outcome such as treatment failure, death, loss-to-follow-up and not evaluated are classified as unsuccessful. A patient that failed to appear in the health facility for more than 2 consecutive months after the scheduled appointment is referred to as  lost to follow-up.  If a patient dies for any reason during the treatment, the outcome  is classified as died.

For patients that move to another health clinic regardless of the cause, the outcome is defined as transferred. Patients transferred out are excluded from the analysis because of the challenges of determining the outcome based on the WHO definition. Outcomes are classified as treatment failure if a patient has positive sputum smears throughout the treatment period or at the end of treatment (even if the patient initially converted from positive to negative). Patients without treatment outcomes are classified as not evaluated either because the tests were not performed or have not completed the treatment.

RECOMMENDATIONS

A key policy outlined in this study is the need to improve the factors highlighted that affect the quality of care. Availability of proper equipment and an increase in service providers for tuberculosis will be effective in addressing the needs of the number of identified patients and enable better detection and identification  of  otherwise  missing cases. This recommendation can be achieved through the following ways:

• Collaboration with private health organizations at the state and local government levels for more primary facilities to be set up in the rural areas with emphasis placed on  reduction  of  patients’  commute  time  and  increment  of  health  service providers at

The study showed that only 14% of facilities had been implementing risk assessment for TB infection, prevention, and control annually. This statistic can be improved by including in the supervision carried out by the LGTBLS, the assessment of the availability of other important documents such as up-to-date  TB policies and guidelines.

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