Improving the Quality of Tuberculosis Care: Tools to assess quality of TB services in high-burden countries

According to the 2018 Global Tuberculosis Report released by the World Health Organization (WHO), tuberculosis (TB) is the tenth leading cause of death worldwide, and the leading cause of death from a single infectious agent. 

Studies show that good quality of care in TB services helps patients and their families meet their health needs safely and effectively. Therefore, there is a need to assess and improve the quality of TB services. MEASURE Evaluation Phase IV, funded by the United States Agency for International Development (USAID), initiated a series of Quality of TB Services Assessments (QTSAs) to evaluate TB service quality in randomly selected health facilities in a number of priority TB countries. The QTSA portfolio was transferred to the TB Data, Impact Assessment, and Communications Hub (TB DIAH) project (also funded by USAID), which is extending assessments to more high-burden TB countries in Africa, Asia, and Europe. 

The purpose of the QTSA is to identify where services are of high-quality and where there are gaps, and ensure that TB patients receive the care that they deserve. The QTSAs assess three domains of quality of care: the structure of the health facility; the service delivery process; and the outcomes of service delivery.

Graphic to breakdown the the QTSAs assess three domains of quality of care: the structure of the health facility; the service delivery process; and the outcomes of service delivery.

The QTSA is conducted using four tools: the Facility Audit, the Provider Interview, the Patient Interview, and the Register Review, all of which MEASURE Evaluation developed with the assistance of USAID. 

The tools exist in a standard format that is adaptable to any country that wants to conduct a QTSA. They are customized to fit the country’s priorities and the context in which they will be used through a multi-stage process involving the National TB Program (NTP). Other tools and/or modules can be added as determined by country interests and needs. 

The multiple modules that make up each of the four standard tools are designed to comprehensively assess the quality of TB services at selected facilities, including screening, diagnosis, treatment, case management, availability and proper upkeep of equipment and supplies, contact tracing, community outreach, infection control practices, provider competencies, patient satisfaction, and an evaluation of outcomes of patients who completed treatment.

The multiple modules that make up each of the four standard tools are designed to comprehensively assess the quality of TB services at selected facilities, including screening, diagnosis, treatment, case management, availability and proper upkeep of equipment and supplies, contact tracing, community outreach, infection control practices, provider competencies, patient satisfaction, and an evaluation of outcomes of patients who completed treatment.

The nationally representative and facility-based QTSAs are conducted in high-TB burden countries in collaboration with the NTP, USAID/Washington, the local USAID Mission, and a local research partner. Results and recommendations are used to develop programs and interventions to improve TB service delivery.

An article written by JSI’s QTSA team and its USAID advisors, Quality of TB services assessment: The unique contribution of patient and provider perspectives in identifying and addressing gaps in the quality of TB services” was published in 2019 in the Journal of Clinical Tuberculosis and Other Mycobacterial Diseases. In 2021, the article was included in Chapter 7 of Quality of Tuberculosis Care, edited by Madhukar Pai and Zelalem Temesgen for the Mayo Clinic, McGill International TB Centre, and TB-PPM Learning Network.

Global QTSA Toolkit 

The Global Toolkit provides detailed information and step-by-step guidelines on how to conduct QTSAs.

Quality of Tuberculosis Services Assessment Global Implementation Guide
Quality of Tuberculosis Services Assessment: Global Implementation Guide

The Global Tools document presents the purpose and content of the QTSA tools. It includes the standard version of the four tools and all the associated consent and assent forms needed. These tools were designed to be administered electronically and may need to be restructured if used in hard-copy format.

The Global Implementation Guide presents the rationale and framework of the QTSA, outlines the QTSA minimum standards and requirements, and provides recommendations for the different phases of the QTSA, namely planning, sampling, implementation, data analysis, and presentation of results. Four annexes include additional advice for editing the QTSA tools, a series of documents useful to the QTSA data collection phase, a QTSA analysis plan outline, and sample dummy tables. The Implementation Guide will be published in 2021.

Country QTSAs

QTSA Map Placeholder
QTSA Map

Final deliverables for each QTSA include a technical report of the assessment that describes the local TB context, the survey method, findings, and recommendations, as well as the English-language country-customized toolkit used for the assessment.

Under TB DIAH

TB DIAH conducted a QTSA in Afghanistan in 2020 (report forthcoming); another is in progress in the Democratic Republic of the Congo.

Democratic Republic of the Congo (20202021)

Report and tools forthcoming

Afghanistan (20192020)

Report and tools forthcoming

Under MEASURE Evaluation

MEASURE Evaluation conducted QTSAs in Nigeria (pilot), the Philippines, Uganda, and Ethiopia between 2018 and 2020. Each QTSA’s report and tools can be found below.

Ethiopia (20192020)

Uganda (20192020)

In Uganda, a focus group discussion guide was added to the QTSA as a fifth tool to collect qualitative data and insights on TB-related stigma among community members from two regions. Stigma hinders prevention, diagnosis, treatment, and care of infectious diseases, including TB. It is a complex social construct shaped by inadequate knowledge and information about modes of transmission, care, and prevention, and is exacerbated by the inadequate availability of and/or poor-quality TB services, especially in rural areas. This qualitative study explored community-level knowledge, attitudes, and perceptions of TB-related stigma to help the NTP  design interventions to improve TB prevention, diagnosis, and treatment in Uganda.

Philippines (20182019)

Nigeria (20182019)

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