Tuberculosis in Tshepo Health District (Free State): A situation analysis

Methodology:
A cross-sectional once-off, assessment was conducted in the Tshepo Health District to rapidly assess the situation regarding TB control and management. Data was obtained from primary and secondary sources. In addition to looking at district-wide data, four primary level facilities were purposively sampled for more detailed research. Interviews were conducted with TB managers, health care workers providing TB services, a pharmacist, a laboratory technician, DOTS supporters and TB patients.

Key findings:
Tshepo appears to be relatively well resourced in terms of medical, nursing and auxiliary staff. One district TB coordinator oversees the provision of TB services in 24 primary level facilities. Each primary level facility has a person identified as the official clinic TB coordinator. Despite remarkable improvements in diagnosis since 1998, and although most patients were diagnosed bacteriologically, there is some evidence of improper clinical diagnostic practice in a number of instances, e.g. some nurses did not know when to conduct a culture test some doctors continue to diagnosis TB through the use of X-rays sisters are ordering sputum and culture tests simultaneously the interpretation of X-rays is difficult and prone to error and there was a misunderstanding that children with TB may be missed if the score sheet is used. A rough analysis of the age distribution indicates a relative under-diagnosis of TB amongst children. There seems to be varying practices when it comes to active case finding and prophylactic treatment. Gaps in health workers&rsquo knowledge about TB include the proper use of the TB register and the treatment of TB patients with HIV. Health education and promotion needs to be addressed.

In search of solutions:
The perception about a shortage of staff needs to be further investigated. Clear guidelines need to be established for active case finding and prophylactic treatment, especially in light of the fact that there appears to be an under-diagnosis of children with TB in the district. Nurses need to be constantly in-serviced on the proper use of the TB register, on the different register definitions used and the value and purpose of all information collected. There is a need for more health care workers to attend workshops and training on TB. Auxiliary staff also play a role in TB management and should be targeted for relevant training. A thorough assessment of the strengths and weaknesses of directly observed therapy in each clinic is required. Health facility staff need to be encouraged to provide effective health education and promotion on TB. The possibility that MDR patients are not being treated according to policy also needs to be investigated. The district needs to develop an appropriate and clearer policy on the voluntary testing and counselling for HIV in all TB patients. Any misunderstandings about the correct management of TB patients with HIV co-infection also needs to be addressed.