Finding Uganda’s missing TB cases: Improved mentorship and supportive supervision could be the answer

 {Photo credit: MSH staff}A district TB and leprosy supervisor conducts supportive supervision.Photo credit: MSH staff

According to the National population based TB prevalence survey, each year, 87,000 Ugandans develop tuberculosis (TB), a preventable and curable disease. Strides have been made to notify more cases. In 2019, the National TB and Leprosy program notified 61,372 cases, leading to a 76% (61,372/80,412) treatment success rate. This was a huge improvement, with a 53% treatment success rate reported three years earlier.

Many patients go untreated due to poor health-seeking behavior and limited access to health services. Health workers may also fail to identify TB symptoms due to lack of skills in TB detection and absence of appropriate test commodities. Weaknesses in recording and reporting detected cases by health workers may delay notification and treatment of already diagnosed patients.

The USAID-funded Uganda Health Supply Chain (UHSC) project, led by MSH, helped the National TB and Leprosy Program develop a comprehensive intervention to close the gaps in TB services in health facilities. Quality TB care saves lives, reduces transmission, and is critical to ending TB and lessening threats to global health security.

Starting in November 2016, UHSC launched a pilot test of the TB Supervision, Performance Assessment and Recognition Strategy (TB SPARS) in 20 districts, covering 202 TB treatment facilities. UHSC trained 40 district TB and leprosy supervisors and district laboratory focal persons in assessing a facility’s performance on indicators, which measured the quality of laboratory diagnosis and infection control, patient care and treatment, logistics management of TB medicines and lab supplies, and record keeping and reporting. Using the results of the assessment, supervisors mentored staff on how to improve their weakest areas. 

In Sembabule, Chris Jjuuko, the district TB and leprosy supervisor, explains that in their nine health facilities, “we discovered that fewer patients with TB were registered. Directly observed therapy status—where a patient takes the TB medicines in the presence of a health worker or family member—was poorly documented.” Directly observed therapy ensures patient adherence to treatment and prevents drug resistance or relapse. Tracking was weak of those patients who had never started treatment after diagnosis or who had started treatment that was later interrupted for two or more consecutive months.

Together, the health staff and supervisors developed and implemented tailored solutions, again working with staff on how to improve areas of weakness, that lead to encouraging results. According to Henry Kawungu, the clinical officer at the Mateete Health Centre III, “we now have more children enrolled in care, and our lost to follow-up patients have also been brought back in for care.”

Health workers were also motivated to take on more active roles to provide high-quality TB services. In the 20 pilot districts, dramatic improvements were made on all TB case management indicators after only five supervisor visits over the 18-month pilot period. The indicator scores for appropriate screening and diagnosis increased from 52% to 86%, treatment follow-up increased from 71% to 86%, adherence to standard guidelines increased from 48% to 78%, and 100% of HIV and TB co-infection cases are now managed correctly, up from 70%. The TB SPARS initiative was given unanimous endorsement from district health officers, NTLP, and implementing partners, who want to see it rolled out countrywide with support from the regional implementing partners.