Quality of TB services assessment: The unique contribution of patient and provider perspectives in identifying and addressing gaps in the quality of TB services.

Ambitious efforts to detect and treat tuberculosis (TB) are required to reduce the burden of disease in low resource settings, and the provision of high quality TB services is critical to reaching global TB targets. The quality of TB services assessment (QTSA) is a facility-based approach aimed at identifying gaps in TB services and prioritizing interventions to improve care across multiple countries with high TB burden. Randomly sampled facilities are assessed with standardized instruments to collect data on structures, processes, and outcomes of TB care, with adaption for local diagnostic and treatment algorithms. The sampling strategy is modified to ensure representation of all levels of the health system where TB services are provided, as well as inclusion of private sector or other facility types relevant to the context. Instruments include a facility audit, provider and patient interviews, and a review of TB registers. A recent QTSA in the Philippines generated important data on provider and patient perspectives on quality of care, showing that providers are more likely to report that they counseled current TB patients on key aspects of TB diagnosis and treatment than patients are to report having received the information. These comparisons highlight areas where refresher training or interpersonal communication and counseling skills may be needed.

Using Patient Pathway Analysis to Design Patient-centered Referral Networks for Diagnosis and Treatment of Tuberculosis: The Case of the Philippines.

Background: Tuberculosis (TB) is the 8th leading cause of death in the Philippines. A recent prevalence survey found that there were nearly 70% more cases of tuberculosis than previously estimated. Given these new data, the National TB Program (NTP), operating through a decentralized health system, identified about 58% of the estimated new drug-sensitive (DS) TB patients in 2016. However, the NTP only identified and commenced treatment for around 17% of estimated new drug-resistant patients. In order to reach the remaining 42% of drug-sensitive patients and 83% of drug-resistant patients, it is necessary to develop a better understanding of where patients seek care. Methods: National and regional patient pathway analyses (PPAs) were undertaken using existing national survey and NTP data. The PPA assessed the alignment between patient care seeking and the availability of TB diagnostic and treatment services. Results: Systemic referral networks from the community-level Barangay Health Stations (BHSs) to diagnostic facilities have enabled more efficient detection of drug-sensitive tuberculosis in the public sector. Approximately 36% of patients initiated care in the private sector, where there is limited coverage of appropriate diagnostic technologies. Important differences in the alignment between care seeking patterns and diagnostic and treatment availability were found between regions. Conclusions: The PPA identified opportunities for strengthening access to care for all forms of tuberculosis and for accelerating the time to diagnosis by aligning services to where patients initiate care. Geographic variations in care seeking may guide prioritization of some regions for intensified engagement with the private sector.