The Institute for Global Health and Development
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Item Decentralising DR-TB care: the trade-off between quality of care and service coverage in the early phase of implementation(International Union Against Tuberculosis and Lung Disease, 2025-09-03) Jassat, Waasila; Moshabela, Mosa; Nicol, Mark P.; Dickson, Laurie; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison D.; Kielmann, Karina; Schneider, Hans G.A policy of decentralised care for drug-resistant TB (DR-TB) was introduced in South Africa in 2011. We describe a trade-off between increasing coverage of services and poor quality of care, in the early phase of policy implementation. This was a mixed methods case study, comparing implementation in KwaZulu-Natal and Western Cape provinces; with interviews and quantitative analysis of routine DR-TB programme data. We analysed qualitative data, thematically organizing findings into inputs, processes, and outputs to explore how decentralisation influenced quality of DR-TB care. Decentralisation of DR-TB care expanded access across provinces but there was wide variation in pace, planning and structural readiness. Where rapid scale-up outpaced capacity-building, weaknesses in resourcing, workforce, and clinical governance compromised quality of care. Two illustrative examples highlight that decentralisation to inadequately resourced sites resulted in morbidity to patients who did not receive effective monitoring for adverse events; and decentralising services to inadequately capacitated clinicians resulted in incorrect initiation in more complex cases and late referral of clinical complications. Attempts to decentralise DR-TB treatment in the context of complex treatment algorithms and limited health system capacity resulted in trade-offs of care quality. We argue that quality of care should be an essential consideration in early implementation of health programmes.Item Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa: a mixed methods study(BMJ Publishing Group, 2023-11-18) Dickson, Lindy; Le Roux, Sacha Roxanne; Mitrani, Leila; Hill, Jeremy; Jassat, Waasila; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison; Kielmann, Karina; Ndjeka, Norbert; Moshabela, Mosa; Nicol, MarkObjectives: Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB. Design: A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements. Participants and setting: People identified with MDR/RR-TB from 13 high-burden districts within South Africa. Outcome measures: Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined. Results: Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0–281 days), average patient distance travelled (12–198 km) and number of health facilities involved in care (1–5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district. Conclusions: Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.Item Drug-resistant tuberculosis patient care journeys in South Africa: A pilot study using routine laboratory data(Ingenta, 2020-01-01) Hill, Jeremy Stewart; Dickson-Hall, Lindy; Grant, Alison D.; Grundy, Chris; Black, John; Kielmann, Karina; Mlisana, Koleka; Mitrani, Leila; Loveday, Marian; Moshabela, Mosa; Le Roux, Sacha; Jassat, Waasila; Nicol, Mark; Cox, Helen SuzanneSETTING: Thirteen districts in Eastern Cape (EC), KwaZulu-Natal (KZN) and Western Cape (WC) Provinces, South Africa.