Background
Methods
Study design
Study settings
Conceptual frameworks and data collection
Dimension | Data collected | Source of information |
---|---|---|
Spatial dimension | Attraction zone | Interviews |
Peripheral structures | Document review | |
Supervision of health centres | Interviews | |
Coordination meetings | Interviews | |
Referral system | Interviews | |
Managerial dimension | Resource generation | Document review, interviews, observation |
Resource management | Interviews | |
Management quality | Interviews | |
Technical dimension | Staff (technical and support staff) | Document review |
Amenities for patients | Observation | |
Technical equipment | ||
Tuberculosis care indicators | Document review | |
General health care indicators | Document review |
Domain | Data collected | Source of information |
---|---|---|
Health service provision
| ||
Distribution of hospital staff in general wards and in the TDTC | Number and type of personnel recruited by the NTCP | Interviews |
Identification of the TDTC nurse | Criteria for recruiting or identifying the TDTC staff | Interviews |
Internal migration from general health care to tuberculosis activities | Number and type of staff dedicated to tuberculosis activities (date) | Interviews |
Implementation of tuberculosis control activities | Type and number of staff involved in tuberculosis care | Interviews Observation |
Role of each staff member | ||
Staff incentives from the NTCP | Salaries provided by the NTCP | Document review Interviews |
Type and amount of incentives related to tuberculosis activities | ||
Provider of the incentives | ||
Human resource generation
| ||
Recruitment of staff for tuberculosis control | Date and reason for change | Interviews |
Training and supervision of staff | Type and date of training by the NTCP | Document review Interviews |
Number and type of personnel trained or supervised | ||
Content of the training | ||
Competencies acquired for general health care | ||
Supervision | Frequency | Document review Interviews Observation |
Supervisors | ||
Supervisees | ||
Subject of supervision | ||
Process of supervision | ||
Acquisition of skills for health care delivery | For tuberculosis activities | Interviews |
For general health care |
Factors | Domain | Data collected | Sources of information |
---|---|---|---|
Technical factors
| Reporting system | Type of new tools introduced by the NTCP and their use | Interviews |
Availability of tuberculosis and routine information tools | Observation | ||
Designer of reporting forms | Designer of the routine information system | Interviews | |
Changes in the design of routine information after TDTC creation | |||
Complexity of the reporting forms | Complexity of the tuberculosis and routine information tools | Interviews | |
Procedures | Rules for tuberculosis and routine data collection,analysis and transmission | Document review | |
Changes in routine HIS procedures following the creation of the TDTC | Interviews | ||
Organisational factors
| Information distribution | Type of reports sent by the hospital before and after the creation of the TDTC | Interviews |
Services receiving hospital reports | |||
Interest devoted to reporting | Motivation of the TDTC staff for reporting | Interviews | |
Motivation of the ward staff members for reporting | |||
Quarterly HIS supervision | Staff members supervised in the use of thetuberculosis HIS (frequency) | Interviews Observation | |
Staff members supervised in the use of the routine HIS (frequency) | |||
Training | Training received on HIS management: trainees and date | Interviews | |
Behavioural factors
| Level of knowledge of content of HIS forms | Staff members involved in monthly routine reporting | Interviews |
Knowledge of the content of HIS tools by hospital staff | |||
Skills | Skills in data collection, processing and analysis | Interviews | |
Motivation | Level of motivation | Interviews | |
Processes
| Data collection | Data completeness in registers (tuberculosis and routine care data) | Observation |
Data processing | Availability of tuberculosis and routine reports(period) at the hospital level | Observation | |
Data analysis | Type of analysis conducted on tuberculosis data and on routine data | Interviews Document review | |
Data transmission | Availability of tuberculosis and routine reports (period)at the district and regional levels | Interviews Observation | |
Data display andfeedback to nurses | Type of data displayed (for tuberculosis and routine care data) | Observation | |
Data quality checking | Procedures of data checking and actors involved | Interviews |
Data collection
-
Document reviewThe documents reviewed were the hospital registers; the monthly, quarterly and annual hospital reports; and the annual district reports. At the regional level, we studied the general and tuberculosis-specific annual reports as well as the directives and guidelines produced by the NTCP.
-
InterviewsWe conducted 35 semi-structured interviews using an interview guide. In total, 3 interviews were conducted at the regional level, 6 at the district level, 20 at the hospital level, and 6 at the first-line health service level. We used a purposive sampling of interviewees. Interviewees were selected on the basis of their responsibilities in the health system and their experience in offering tuberculosis care. At the district level, we selected the district medical officers, hospital directors, nurses in charge of a ward, nurses in charge of the TDTC, and head nurses at first-line health services (health centres). Starting from the initial selection, other participants were identified using a snow-ball strategy until we reached saturation. At the regional level, three health professionals associated with NTCP coordination were interviewed.The interview guide was adapted after a preliminary analysis of each interview. Notes were taken during interviews and were used to complete the interview content. The interviews were conducted in French, lasted from 30 to 90 minutes and were audio-taped. A full transcription of all interviews was written using Microsoft Word 2007 software. We used NVivo 9 QSR International Pty Ltd software (Victoria, Australia) to analyse the interviews.
-
ObservationWe observed the supervision of tuberculosis activities at the TDTC level –these supervision were done by the NTCP staff from the regional and central levels -, the staff meetings, the routine work of staff, and the flow of patients between and within hospital units. We made an inventory of the infrastructure, equipment, medications and staff available per unit.
Ethical issues
Results
Performance of DHA and DHB
Spatial dimension
Managerial dimension
Characteristics | District hospital A | District hospital B | |
---|---|---|---|
Governing bodies | Committee | Regional faith-based coordination committee of the Health | Hospital management committee |
Hospital Management Board | |||
Leadership | Leadership strength | Strong | Weak |
Shared | Centralised at the directorate level | ||
Resources generation | User fees collected | 222.49 million FCFA 86% of revenues managed by the hospital in 2010 | 37.9 million FCFA, 77% of revenues managed by the hospital in 2010 |
Subsidies from the Ministry of Health | Irregular funding (35.4 million FCFA in 2010) used on the basis of hospital needs | Regular lump funding every six months used on the basis of directives from the central directorate (progressively decreased from 15.4 million FCFA in 2001 to 10.84 million FCFA in 2010) | |
No wages paid to staff | Wages to technical staff | ||
Search for external funding from donors | Pro-active | Low | |
Regular external support in terms of technical expertise, equipment, drugs, infrastructure rehabilitation and construction from foreign organisations | Little support from local associations in 2010 (beds and mattresses) | ||
Management | Scope of management practices | Related to faith-based values | Administrative procedures |
Financial resources | Based on hospital needs and strategic plans | Based on guidelines from the Ministries of Health and of Finances, and are bureaucratic | |
Human resources | Decentralised management by hospital committees | Centralised management | |
Feedback to staff | Openly discussed at weekly meetings | Rare, with some aspects withheld | |
Maintenance | Well-equipped support services (e.g., woodwork, electricity and plumbing) | Scarce support service | |
Support and administrative staff | 22 | 9 | |
Human resources | Number of staff | Technical staff: 41 | Technical staff: 23 |
Medical doctors | 2 (2003–2006); 3 (2007–2010) | 1 (2003–2006); 3(2007–2010) | |
Inhabitants per medical doctor | 50,872 inhabitants | 23,817 inhabitants | |
Equipment | Number of beds | 157 | 49 |
Technical equipment | Good | Poor | |
Radiograph, 2 echographs, Mammograph, cardiotopograph, 2 well-equipped surgical theatres, electronic sphygmomanometers in each ward, oxygen | A small surgical theatre with little equipment | ||
Amenities for patients | High-quality ward | Not available | |
Tap water and electricity permanently available | Tap water only available in the morning, frequent electricity cut-offs |
Technical dimension
-
ResourcesThe capacity of the DHA (157 beds) is three times higher than that of DHB (49 beds). The DHA is technically well-equipped and has more amenities for patient comfort (see Table 4). There was a 30-beds ward for tuberculosis inpatients and a nurse only in charge of tuberculosis patients. Additionally, support services for administrative duties, hygiene and sanitation, and maintenance are well-equipped, while these services are scarce and poorly-equipped in DHB. In 2007, the DHB welcomed two medical doctors and 10 nurses from the Ministry of Public Health while in the health district A only public health centres received these additional staff.
-
General health care indicatorsThe number of outpatients in the DHA has progressively decreased from 143 patients per 1000 inhabitants in 2002 to 50 patients per 1000 inhabitants in 2010 (see Table 5). Interviewees explained that, due to the creation of many new public and private health centres, the number of primary cases received at the hospital level had progressively diminished, and currently, cases received are more severe –suggesting a more appropriate pattern of health services utilisation in the district. Indeed, the proportion of outpatients hospitalised increased from 15% in 2003 to 46% in 2010. Despite the poor registration of referred and counter referred patients, the referred patients registered represent 4% to 6% of outpatients. Admission rates were approximately 24 inpatients per 1000 inhabitants between 2002 and 2010.In the DHB, the number of outpatients decreased from 32 to 27 outpatients per 1000 inhabitants between 2002 and 2006 and rose after 2006 to reach 52 outpatients per 1000 inhabitants in 2010. The referred patients among outpatients represent 1% to 4%. Interviewees highlighted that additional staff, as well as new laboratory equipment received in 2007 contributed to improve the capacity and the functionality of the hospital. Admission rates ranged between 8 and 16 inpatients per 1000 inhabitants, and had progressively increased since 2007.
-
Tuberculosis control at the DHA and DHBData on tuberculosis control activities were available from tuberculosis registers from 1990 to 2011 and from 1998 to 2011 at the DHA and DHB respectively, while a synthesis of the Adamaoua regional tuberculosis data was only available since 2004. The tuberculosis notification rates of the DHA from 1998 to 2011 were 5 to 15 times higher than those of the DHB (see Figure 1). Between 2004 and 2011, the notification rates of the DHA were 1.1 to 1.6 times higher than those of the Adamaoua region that were at the same time 3.6 to 12.3 higher than the notification rates of the DHB. From 2009 to 2011, the Adamaoua notification rates were similar to the national notification rates.The DHA achieved the NTCP objective of detecting at least 70% of SPPT cases per year despite the presence of a second TDTC in the district, whereas the DHB detected less than 50% of cases. However, some patients come from outside the district boundaries. One staff member of DHB explained that ‘before 2006, the hospital was just like a health centre, and the laboratory could only perform the same exams as in health centres’. The DHB did not have the necessary equipment –such as a radiograph, reagents for biopsy conservation - to improve the diagnosis of extra-pulmonary and smear negative pulmonary tuberculosis cases. This contrasts with DHA that was in a position to perform chest radiography and biopsies on suspected tuberculosis cases with negative sputum smears. Since 2003 –when data collection for tuberculosis care was standardized- SPPT cases ranged between 25% and 65% of all tuberculosis cases in DHA, and between 64% and 100% in DHB.From 2005 to 2010, cure rates were between 51 and 84% at DHA, and between 61 and 78% at DHB.
Hospital | Indicators | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 |
---|---|---|---|---|---|---|---|---|---|---|
A | Outpatients received | 16956 | 20177 | 13773 | 8852 | 11673 | 11168 | 10937 | 9177 | 7398 |
Outpatients/1000 inhabitants per year | 143 | 166 | 110 | 69 | 88 | 82 | 78 | 63 | 50 | |
Inpatients | NA | 3014 | 3247 | 3140 | 3196 | 3308 | 3371 | 3268 | 3386 | |
Inpatients/1000 inhabitants/year | NA | 25 | 25 | 24 | 24 | 24 | 24 | 23 | 23 | |
B | Outpatients received | 2463 | 2878 | 2113 | 2191 | 2271 | 2445 | 3183 | 3505 | 4986 |
Outpatients/1000 inhabitants per year | 32 | 37 | 26 | 27 | 27 | 28 | 35 | 38 | 52 | |
Inpatients | 744 | 790 | 738 | 675 | 716 | 954 | 1147 | 1538 | 1539 | |
Inpatients/1000 inhabitants per year | 10 | 10 | 9 | 8 | 8 | 11 | 13 | 17 | 16 |
Effects of the NTCP on DHs
Health service provision | District hospital A | District hospital B |
---|---|---|
Stock of personnel | No additional staff recruitment | No additional staff recruitment |
Criteria for identifying the TDTC staff | Availability, seriousness, obligingness | Availability, seriousness, obligingness |
Internal migration from general health care to TB activities | Since 2008, one assistant nurse dedicated to the TDTC | Partial migration: the TDTC nurse was head of a ward (surgery from 2003 to 2008 and medicine since 2009) |
One laboratory technician dedicated to sputum smear processing | ||
Labour force activity | Detection of suspect tuberculosis patients by consulting nurses Processing of sputum smears by a dedicated laboratory technician | Detection of suspect TB patients mainly by medical doctors |
Drugs dispensation, follow up of hospitalized tuberculosis patients and reporting by the TDTC nurse | Processing of sputum smears by all laboratory technicians | |
Chest radiography by a specialized nurse | Drugs dispensation and reporting by head nurse of the medicine ward | |
human resources generation
| ||
Earnings | No staff paid by the NTCP | No staff paid by the NTCP |
Incentives | 15000 FCFA given to the TDTC nurse per trimester since 2010 | 15000 FCFA given to the TDTC nurse per trimester since 2010 |
Fees for sputum smear managed by the TDTC nurse | Fees for sputum smear included in hospital revenues | |
Productivity | No patient increase following the TDTC creation | No patient increase following the TDTC creation |
Education and training | Competencies gained on counselling, treatment of respiratory tract infections, smear processing and reading of slides on microscope by trained staff | Competencies gained on counselling, treatment of respiratory tract infections, smear processing and reading of slides on microscope by trained staff |
Workshops organized on tuberculosis care for TDTC staff and hospital managers | Workshops organized on tuberculosis care for TDTC staff and hospital managers | |
Quarterly supervision of the TDTC staff by the NTCP coordinators | Quarterly supervision of the TDTC staff by the NTCP coordinators |
Frequency | Type of inputs | District hospital A | District hospital B | Observations |
---|---|---|---|---|
Permanent allocation since 2003 | Drugs | Anti-tuberculosis drugs for adults and children | Anti-tuberculosis drugs for adults only | Frequent out-of-stocks registered |
Reagents | Sulfuric acid, Methylene blue, Fuschin | Sulfuric acid, Methylene blue, Fuschin | Reagents used for sputum smear processing; used for other tests for non-TB patients | |
Other laboratory materials | Slides and sputum collectors | Slides and sputum collectors | Equipment used for all patients | |
Sporadic allocation | Logistics | One motorcycle in 2006 | No motorcycle | The motorcycle is used for other hospital outreach activities |
Equipments | Two electric microscopes in 2003 and 2007 | Two electric microscopes 2003 and 2006 | Equipment used for all patients | |
Infrastructures Rehabilitation | No rehabilitation | Rehabilitation of a small building in 2006 | The unit rehabilitated in 2006 at the DHB is out of use | |
Finances | 15000 FCFA quarterly allocated to each TDTC | 15000 FCFA quarterly allocated to each TDTC | Office equipment insufficient in both TDTC | |
Sputum smear fees collected and managed by the TDTC nurse |
Technical factors | District hospital A | District hospital B |
---|---|---|
Reporting system | Printed tuberculosis tools (registers, patient treatment card, 2 quarterly reporting forms) introduced by the NTCP in 2003 | Printed tuberculosis tools (registers, patient treatment card, 2 quarterly reporting forms) introduced by the NTCP in 2003 |
Printers registers for routine HIS | Registers manually designed for routine HIS | |
Designer of reporting forms | NTCP for the tuberculosis HIS | NTCP for the tuberculosis HIS |
Ministry of health for the routine reporting form | ||
Managers of the hospital for registers | ||
Central level of the church for registers and reports | ||
Software for HIS | No | No |
Computers acquired from hospital resources | Computers acquired from hospital resources | |
Recruitment of a HIS staff | No for tuberculosis HIS | No |
Yes, in 2008, but only in charge of routine reporting and paid from hospital revenues | ||
Skills of the HIS staff in using computer | No specific training on HIS management | No specific training on HIS management |
Complexity of the reporting forms | Simple for tuberculosis tools but takes too much time | Simple for tuberculosis tools but takes too much time |
Filling routine registers is easy | Filling routine registers is easy | |
Procedures | Simple | Simple |
Organisational factors
| ||
Information distribution | Reports sent to the regional NTCP coordination since 2003 (completeness: 100%) | Reports sent to the regional NTCP coordination since 2003 (completeness: 100%) |
Routine reports sent to the district till 2006, but regularly to the Church hierarchy | Routine reports sent to the district in 2010 | |
Interest devoted to reporting | Very high for the NTCP | Very high for the NTCP |
Low for routine reports | Low for routine reports | |
Supervision | Quarterly by the NTCP coordinators, all tuberculosis tools reviewed | Quarterly by the NTCP coordinators, all tuberculosis tools reviewed |
Rare for routine activities | Rare for routine activities | |
Training | No specific training on HIS | No specific training on HIS |
Finances | No additional resources for HIS | No additional resources for HIS |
Allocation of computer | Computers acquired from hospital resources | Computers acquired from hospital resources |
Allocation of reporting forms and other materials | Tuberculosis reporting tools provided by the NTCP | Tuberculosis reporting tools provided by the NTCP |
Routine registers provided by the Church | ||
Behavioural factors
| ||
Level of knowledge of content of HIS forms | Very good for tuberculosis HIS, low for staff working in ward | Very good for tuberculosis HIS, low for staff working in ward |
Data quality checking skills | Good for the TDTC nurse | Good for the TDTC nurse |
Routine data rarely checked | Routine data checked by the Director | |
Competency in HIS tasks | Low | Low |
Motivation | Very high for the TDTC staff | Very high for the TDTC staff |
Low for other staff | Low for other staff | |
Problem solving tasks | Only raw data transmitted | Only raw data transmitted |
Processes
| ||
Data collection | Data rigorously filled in tuberculosis registers | Data rigorously filled in tuberculosis registers |
Incomplete routine data collection | Incomplete routine data collection | |
Data processing | All quarterly tuberculosis reports done since 2003 | All quarterly tuberculosis reports done since 2003 |
Lot of missing routine reports | All routine monthly reports done since 1998 | |
Routine reports not done since 2006 | ||
Data analysis | Little analysis | Little analysis |
Data transmission | Completeness : 100% for tuberculosis reports | Completeness : 100% |
Routine information transmitted only to the faith-based hierarchy | Only the 2010 routine reports sent to the district level | |
Data display | No | No |
Data quality checking | Yes for tuberculosis reports | Yes for tuberculosis reports |
No for routine reports | Rarely for routine reports | |
Feedback to ward nurses | No | No |
Effects of the NTCP on human resources
-
Health care provisionIn the DHA, the nurse in charge of the tuberculosis ward was changed quarterly until 2006 (see Table 6). Following the NTCP instructions, one laboratory technician processed all sputum smears, and one assistant nurse was assigned the task of permanently taking care of tuberculosis patients. A hospital manager however argued that staff were regularly changed so that more nurses could master tuberculosis care and to prevent individual staff members from being overexposed to the tuberculosis bacilli. He/she added that this strategy contributed to maintaining the continuity of care. The TDTC nurse noted that because ‘I am alone, I receive patients until the office closes, and I do not have time to trace defaulters’. The defaulting rate of SPPT was 9% in DHA in 2010 and in 2011, but dropped in DHB from 17% in 2010 to 6% in 2011.In the DHB, the TDTC nurse was the head nurse of the surgery ward from 2003 to 2008 and has been the head of the medicine ward since 2009. All laboratory technicians processed sputum smears. The TDTC nurse noted that being the only person to deliver care to tuberculosis patients ‘represents a problem for continuity of tuberculosis care; when I am absent or on leave, nobody is qualified to follow patients’. He further added that ‘this does not influence too much my work as head nurse of the medicine ward, as I follow only around 30 tuberculosis patients per year’. A regional tuberculosis coordination staff member noted that with nurses specifically designated for tuberculosis control, following up on recommended measures for TDTC was easier. Regarding the organisation of tuberculosis care, suspected tuberculosis patients follow more or less the same flow as any other patient undergoing consultation for curative care in both hospitals. The consulting staff of both hospitals screens suspected tuberculosis cases among outpatients and sends them to the laboratory for a sputum smear examination. Additionally, at DHA, chest radiography is performed and interpreted by a specialised nurse. After the diagnosis of tuberculosis is made, the patients are referred to the TDTC nurse. The TDTC nurse delivers anti-tuberculosis drugs, fills in the tuberculosis data collection tools and gives quarterly reports. Health centre nurses are only passively used in tuberculosis control (see Figure 2). The two TDTC nurses were unable to identify interventions for tuberculosis control directed toward health centre staff. In both hospitals, the criteria mentioned by managers for selecting the TDTC nurses were availability, seriousness, and attention to their duties.
-
Human resource generationThe NTCP has not allocated additional staff to either hospital. Regarding competencies, the district medical officer, the director of the hospital, a nurse and a laboratory technician from each district were trained in clinical and laboratory diagnosis and treatment of tuberculosis, and in tuberculosis reporting systems prior to the launch of the TDTC in 2003. Briefings were organised at the hospital level for other staff. However, nurses trained in tuberculosis care have been transferred out of both hospitals to other health facilities since 2008. Since 2004, the TDTC nurse and one laboratory technician per TDTC in each hospital have been supervised 3 to 4 times per year by the regional NTCP coordinators and once per year by a NTCP manager from the central level. The supervisions focus on reviewing tuberculosis data collection and reporting tools, and on assessing the implementation of tuberculosis control directives. However, the NTCP coordinators bypass the DHS to supervise and directly monitor tuberculosis care in the two DHs. Additionally, the nurses working in the outpatient departments in both hospitals and the specialised radiograph technician of the DHA have never been trained in tuberculosis diagnosis and treatment, nor have they been supervised by the NTCP.Concerning the supervision of routine activities by the DHS, all health centre nurses and hospital managers in both health districts explained that they were primarily supervised during mass immunization campaigns by people coming from the district, regional, or central level or from international organisations.At the health district A, a DHS staff member stated that ‘we are not invited to supervise; the regional staff of the tuberculosis programme just inform us by phone when they arrive at the DH for supervision’. Another member of the DHS explained that health centres were only supervised 2 to 3 times per year if they received support from programmes. Concerning the supervision of the hospital, this staff member added that ‘we do not supervise the hospital because if we ask for data that could have a link with their financial revenue, they do not provide them to us’.In DHB, a laboratory technician stated that ‘the supervisor teaches us how to process and read sputum smears, and I use this competency for other exams, such as blood smears’. The TDTC nurse acknowledged that skills acquired in counselling were used to improve communication with non-tuberculosis patients. A member of the DHS noted that that, ‘before 2008, the district medical officer was also the director of the hospital; however, since 2009, the tuberculosis supervisors merely inform the district medical officer and supervise independently’. Long distances and competing priorities were given as the main reasons for the lack of supervision of health centres.
Effects of the NTCP on the technical capacity of DHs
Effects of the NTCP on the routine HIS of DHs
-
Technical factorsIn both hospitals, the NTCP introduced standardised printed registers and tools for data collection and reporting on tuberculosis. There is one register for sputum smear results and another for diagnosed tuberculosis cases. There are also two quarterly reporting forms: one for tuberculosis cases detected during the previous trimester and one for the tuberculosis prognosis of cases detected 9 months earlier. The two TDTC nurses acknowledged that ‘completing these registers is simple even if it takes a lot of time’.The NTCP has not modified the routine data collection and reporting tools. Registers for routine data collection are printed locally in DHA and manually designed in DHB, with contents varying between wards and over time. In the DHA, the monthly routine information tool designed by the Ministry of Public Health has not been available since 2004. Computers are available in both hospitals and DHS offices, but there is no specific software for managing HIS.Other programmes, such as for malaria, HIV/AIDS, and immunisation, have their own data collection and/or reporting tools. There were neither standardised routine data collection registers for hospitals nor a standardised reporting tool that bundled data from specific programmes and general care.
-
Organisational factorsEach processed sputum smear is registered at the laboratory in both hospitals. Following the receipt of laboratory results, patients diagnosed with tuberculosis are registered by the TDTC nurse who each quarter manually collates and records data on the two reporting forms. The reports are directly sent to the regional coordinator by both TDTCs, bypassing the district level. During the TDTC supervision activities that we observed, all tuberculosis data collection tools and reports were checked for accuracy. There was, however, no supervision for the routine HIS. An annual evaluation meeting was organised at the regional level for tuberculosis control activities, but it was only attended by the TDTC nurses and hospital directors. This meeting focused on validating the annual quarterly tuberculosis reports of each TDTC and on planning for the year. Internet services are available in both hospitals and DHS offices, but no electronic transmission of data or provision of feedback is available.In both hospitals, routine inpatient and outpatient data are inputted manually in specific registers. At the end of the month, the nurses in charge of a ward manually collate the data.In the DHA, the person in charge of health statistics uses the ward data to complete the Excel spreadsheets designed for that purpose. Some indicators are automatically calculated and compared with previous periods. This report is sent each month to the Church’s Health Department.No specific indicator related to hospital care is calculated for the DHB, as the nurses in charge of the wards send the data to the superintendent, who then fills them using the monthly HIS tool designed by the Ministry of Public Health.Overall, the tuberculosis control HIS was designed in parallel with the routine HIS in both hospitals.
-
Behavioural factorsTDTC nurses are highly motivated and take care to properly complete their reports. They have progressively acquired skills in the collection, verification and collating of data on tuberculosis.At the DHB, the TDTC nurse stated that ‘tuberculosis reports are carefully checked to avoid errors, as the supervisors will review these reports and registers’. He added that ‘this attitude helps me to pay particular attention to my monthly report of the medicine ward, but the routine report is not checked’. Additionally, a hospital manager argued that ‘nobody cares if you complete or submit your general monthly report’. A nurse in charge of a ward noted that ‘other nurses are not motivated to complete the registers, and they consider reporting to be an additional task not related to their activities’.This situation was in line with what a nurse in DHA noticed; namely, ‘there is too much work and too little time for filling in all the registers and doing reports’. Also, the nurse in charge of the statistics in DHA who was recruited in 2008 noted that he has never seen the hospital routine reporting form designed by the Ministry of Public Health.
-
Routine information processesIn both hospitals, we observed that routine registers were not correctly completed and that there were missing data for some patients, such as their age, gender, and prognosis. From to 2003 to 2010, tuberculosis registers and reports were rigorously filled in, were well maintained, and had the supervisors’ recommendations written on them. The TDTC nurses compiled the tuberculosis data without further analysis. The role of the DH managers in running the HIS was limited to transmitting the data to the regional level; no local analysis of these data was performed (see Figure 2). Before 2003, the tuberculosis registers in the two DHs had lot of missing information such as the demographic characteristics of the patients, the type and the prognosis of the tuberculosis cases.In DHA, routine reports designed by the Ministry of Public Health were only sent to the DHS from 1998 until 2004, but the hospital regularly sends reports to the Church’s Health Department. In DHB, only the 2010 monthly reports were found at the DHS level and lacked any analysis. At the regional level, only few routine monthly hospital reports were found for the entire region.
Adaptive measures
Missed opportunities for building synergies between the NTCP and the local health system
Domains | Missed opportunities |
---|---|
Human resources
| Recruitment of additional staff |
Identification of training needs for DHs and health centres staff members | |
Organisation of in-service training with the support of regional disease control programmes managers | |
Reinforcement of competencies of the district management teams in organizing, monitoring and evaluating tuberculosis control activities | |
Implication of district management teams in the supervision of TDTC | |
Health Information System (HIS)
| Standardisation of routine data collection tools for all DHs |
Elaboration of a unique data reporting tools that bundles routine and programmes’ data | |
Development of software for managing health data at DH and DHS levels | |
Utilisation of the electronic system for data transmission and feedback between DHs, DHS and regional programme coordinations | |
Reinforcement of capacities of district management teams and DH staff in the management of HIS for decision-making | |
Technical capacity
| Identification of hospital technical needs and allocation of resources on the basis of hospital needs |
Submission of health system strengthening proposals to the Global Fund against HIV/AIDS, tuberculosis and malaria | |
Health service delivery
| Organization of the referral system |
Development of the collaboration between HIV/AIDS and tuberculosis care at facility level |