Global policy to local implementation : experiences from active tuberculosis case-finding in high-burden countries

Abstract

Background: Tuberculosis (TB) is one of the world’s leading infectious killers. Every year, an estimated 10 million people fall ill with the disease, of whom 2.9 million people are never diagnosed and treated. Thirty low- and middle-income countries account for almost 90% of the global TB burden. The World Health Organization’s (WHO) End TB Strategy highlights active case-finding (ACF) as one approach to finding people with TB who are currently being missed by health services. ACF has been shown to find more people with TB at an earlier stage of the disease compared to passive case-finding. Passive case-finding is the standard approach to TB screening, relying on people seeking care when they have TB symptoms. Given the relatively limited evidence on both the epidemiological impact of ACF and optimal implementation strategies, questions remain about what influences ACF policy development and implementation and how these processes can be improved. This thesis aims to contribute to the knowledge base on ACF policy development and implementation in high TB burden countries.

Objectives: To review antecedents, components and influencing factors for ACF policy development and implementation based on the literature. To explore how international experts and National TB Programme (NTP) managers from high TB burden countries perceive ACF policy development and implementation, and to identify facilitators, barriers and “how-to” strategies for ACF implementation in Nepal and Vietnam, which serve as example countries.

Methods: A scoping review of the literature (n=73) was performed, and a frequency and thematic analysis applied. Qualitative semi-structured interviews were conducted with 39 experts from a variety of institutions worldwide. The experts’ perceptions were analysed using framework analysis. A mixed methods survey with NTP managers (n=23) was implemented, yielding both quantitative and qualitative data. The data were analysed in parallel and merged in the interpretation of the findings. The survey results were further complemented by a narrative review of national TB strategic plans (n=22). Qualitative semi-structured interviews were conducted with 17 key-informants in Nepal and 39 key-informants in Vietnam. Participants comprised implementers of ACF and people with TB identified through ACF. Thematic analysis was applied, using an implementation science framework.

Results: The results presented in this thesis provide insights into experiences with ACF, from global policies to local implementation. Study I: The evidence base for ACF has been growing, especially since 2010. Although much is known about factors influencing ACF implementation (e.g., resources), evidence on what influences ACF policy development (e.g., politics) remains scarce. Articles described the WHO’s recent emphasis on ACF as a crucial antecedent of the increasing interest in ACF, especially in high TB burden countries. Study II: Experts had a wide range of views on ACF, from ACF being a “waste basket” for resources to it being “common sense” and something that should be done. They described the influence of and “power plays” between donors, governments and non-governmental organisations on ACF policy development and highlighted the need for different types of evidence to inform ACF policy development and implementation. Experts also stressed the importance of existing systems, processes and experience in influencing ACF implementation, e.g., ACF could build on experience from other screening programmes. Study III: Perceived benefits of ACF were linked to its objective of finding people with TB early, while ACF was also perceived as a “double-edged sword” that could cause harm, if inappropriately designed and implemented. Study IV: NTP managers unanimously agreed on the need for ACF scale-up in high TB burden countries. This was also reflected in the national TB strategic plans, even though not all documents included explicit aims and targets related to ACF. At the same time, 90% of the NTP managers also described a lack of financial and human resources for ACF. Strategies to increase resources included generating local evidence for advocacy. Managers in districts or regions were the only ones among a list of stakeholders that NTP managers considered crucial for both ACF policy development and implementation. Studies V and VI: In Nepal and Vietnam, the main themes revolved around how people (the implementers and people with TB) could “make or break” TB screening, but also how projects could provide a context that is conducive to ACF implementation (e.g., through human resources, equipment and training). Many similar facilitators and barriers for ACF implementation were identified in Nepal and Vietnam, such as the implementers’ dedication, motivation, skills and network. Barriers and facilitators at the societal and organisational levels were more context specific. For instance, in Nepal, poverty and community support were mentioned as critical. In Vietnam, participants elaborated on the importance of commitment and support from various stakeholders for ACF implementation. In both countries, the implementers requested increased incentives and training.

Conclusions: Based on these results, evidence remains limited with regards to factors influencing ACF policy development. Experts have opposing views on ACF policy development and implementation, while NTP managers unanimously agree on the need for ACF scale-up, which is also reflected in the national TB strategic plans. Yet, 90% of the NTP managers state that human and financial resources are currently insufficient, and funds for ACF might have to be sought from alternative domestic and external sources. Benefits and harms of ACF must be considered throughout the screening and diagnostic pathway to avoid possible negative effects for people screened, as well as communities and health systems. Furthermore, the use of different types of evidence and the engagement of stakeholders (e.g., managers in districts and regions) are necessary to mitigate “power plays” that might otherwise mislead ACF policy development and implementation. Most facilitators, barriers and “how-to” strategies for ACF implementation identified in Nepal and Vietnam are similar across contexts, but there are also nuances, e.g., based on the predominant social determinants of TB. ACF projects can provide a context that is conducive to ACF implementation, but implementation success still depends on individuals. Ultimately, if done well, ACF can be an important, complementary tool to contribute towards ending TB, while more resources and evidence are needed to improve ACF policy development and implementation.