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Root Cause Analysis of Low Performance in Percentage of Target TB Notification Achieved

 

Low performance means notification of TB cases is not happening as desired.

Data is available in Ni-kshay and analysed in terms of: 

  • Whether the notification is less from a geographical area? (Peripheral Health Institute (PHI)/ TB Unit (TU), private hospital) - Place Analysis 
    • e.g., less notification from a particular PHI may be due to a newly recruited Medical Officer (MO) who is not trained in National TB Elimination Programme (NTEP). The solution should aim at training the MO to improve the notification from that PHI.
  • Whether the notification is less in special age group/ gender/ population group?- Person Analysis
    • e.g., teen-aged female patients due to attached stigma. Identification of the stigma by such analysis might be helpful in planning stigma reduction campaigns/ Advocacy, Communication and Social Mobilisation (ACSM) activities to enhance notification.
  • Whether there is a change in notification trends across months? - Time Analysis
    • e.g., festive season and marriage season might have less notification, as many patients neglect cough or chronic ill-health. However, this might be dangerous as the probability of spread during such festivals and marriage functions is quite high. Such analysis gives insights for enhanced active case finding during these seasons.

The notification depends on the presumptive TB examination rate. Look at the trends of presumptive examination rate. The expected is about 1500/ lac population.

Some of the reasons and suggested solutions for decreased TB notification are listed below.

Domains Possible Problems Suggested Solutions

 

Patient
  • Lack of awareness regarding TB symptoms, fear of stigma/ lack of motivation to seek health care
  • Accessibility to health care services
  • Financial reasons
  • Advocacy communication and social mobilisation (ACSM)
  • Targeted Information, Education and Communication (IEC) for high-risk groups
  • Community mobilisation through Accredited Social Health Activists (ASHA), Non-government Organisations (NGOs), volunteers
  • Steps to set up a Designated Microscopy Centre (DMC), if indicated
  • Steps to minimise out-of-pocket expenditure through mobile testing facilities and point-of-care testing
PHI

 Is the poor referral for testing due to:

  • Presumptive TB cases not seeking care
  • Due to deficient knowledge of the staff
  • Due to lack of facilities for sputum collection/ transportation
  • Due to lack of diagnostic services
  • Vulnerability mapping of all the residents of the PHI area to identify high-risk cases and conduct active and intensified case-finding efforts
  • Provider-oriented IEC, training and periodic reinforcement
  • Arrange facilities for sputum collection and transportation(Hub and spoke model)
  • Enquire regarding the possibility of a DMC in the area
Private Hospital
  • Deficient knowledge of the provider regarding the NTEP programme/ TB notification
  • Lack of diagnostic facilities
  • Lack of trust in the system or poor rapport with NTEP staff
  • Fear of losing the patient
  • Provider-oriented IEC, training, capacity building and periodic reinforcement steps for linkage to a diagnostic facility or enquire the possibility of setting up one through the PPP model
  • Steps for private sector engagement
  • Establish a system for diagnosis notification and treatment support for TB cases and supportive supervision
Testing and Diagnosis
  • Lack of skilled Human Resource (HR)
  • Lack of facilities
  • Arrange to recruit more HR/ training available HR
  • Periodic training and reinforcement, monitoring and quality check helps
  • Ensure adequate supply chain management
  • Linkage to diagnostic facilities/ set up new facilities 

Notification

 

Not entering the data to Ni-kshay due to:

  • Lack of awareness
  • Technical reasons - internet issues
  • Training and capacity building along with periodic reinforcement, proper monitoring 
  • Steps to minimise the internet connectivity issues
Other causes
  • Is the number needed to test to detect one case of TB high?
  • If so, is the estimated target is correct?
  • Brainstorm with District TB Officer (DTO)/ State TB Officer (STO), and the stakeholders to reach a conclusion

 

Resources

 

Assessment

Question Option 1 Option 2 Option 3 Option 4 Correct answer Explanation Page id Pretest Post-test
Which of the following is an exception to the steps for improving performance in target TB notification? Increasing the number of presumptive TB cases examined By active case finding By improving diagnostic facilities By initiating TB treatment   4 Treatment initiation is done after the notification process.      

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