Despite the availability of TB guidelines/ standards in high burden TB countries, provider adherence remains a challenge. In most cases, provider adherence to guidelines is not a problem of individual performance, but a problem located in the health system itself – at the political, health services, community, and patient levels.

Between 2011-2012, TB CARE II conducted multi-country studies in Bangladesh, Zambia, and Kenya to gather information on: (1) Knowledge and skills of providers to provide standard TB services; (2) Providers’ compliance with national and service delivery standards; (3) Existence of systems for maintaining TB service delivery capacity; and (4) TB patients’ perceptions of quality of care received at facilities.

Some general findings included:

  • While all health facility managers had access to adult TB guidelines, fewer had access to specific guidelines, such as for MDR-TB and TB-HIV.
  • Some new guidelines had been developed by the NTP but not yet disseminated, illustrating a system delays in getting guidelines from the NTP to facility levels.
  • While most facilities had functioning TB register systems in place, issues were found such as data from monitoring TB activities not being always used for decision-making, scheduling a follow-up, recording of symptoms and contact tracing mechanism was much less often done.
  • TB drug shortages were reported by many health facility managers.
  • There appeared to be a training-knowledge gap: most providers had been trained but many did not have adequate knowledge about TB, including those at highest risk of TB; treatment of TB in pregnancy; and TB testing in HIV+ patients.
  • While all countries had a functional TB supervisory system in place, supervision was not always done as often as stipulated by guidelines and adequate follow-up was not always being provided.
  • There were gaps in the information health providers communicated to TB patients or those with TB symptoms – especially having to do with information about side-effects of TB treatment; the need to have family members and close contacts screened for TB; not linking all patients to DOTS support; and for the countries with high HIV prevalence offering HIV counseling and testing to patients with unknown HIV status and referring HIV positive patients for ART.

More detailed findings are provided in each of the three country reports: BangladeshZambia, and Kenya.