Scaling up community MDR-TB care: experiences from 14 districts in South Africa Background: South Africa faces a growing burden

of drug resistant tuberculosis (DR-TB), fuelled by the HIV co-epidemic. The DR-TB programme faces many challenges including delayed initiation of treatment and poor adherence to treatment. To address these challenges, the National Department of Health has endorsed a policy framework on decentralisation and deinstitutionalisation of Multi-Drug Resistant TB services. We identified a need to support districts to operationalize the policy. The project is funded by the USAID TB Program for South Africa. Intervention: We conducted multidisciplinary workshops (provincial, district and subdistrict management, facility managers and clinicians), to discuss and develop plans for decentralising DR-TB services in 38 districts in eight provinces. 14 districts were selected through a process guided by geopolitical dispensation and readiness to decentralise DR-TB services. 19 facilities were assessed to determine readiness and collect baseline data. 633 healthcare workers (medical officers, nurses, pharmacists, TB assistant officers, and lay counsellors) were trained. Support and monitoring visits were conducted to the districts to provide technical assistance. More than 2000 MDR-TB patients have received care in the community in supported districts over the two years of project implementation. Lessons Learnt: Strengths include the buy-in by national, provincial and district level management, and support by recipient facilities. Systems barriers include poor communication between levels of care, poor knowledge of DR-TB programmatic management (PMDT) at district level and clinical management at decentralised levels, DRTB recording and reporting challenges, lack of financial and other resources (e.g. availability of vehicles for outreach teams; inadequate infrastructure for infection control). Solutions range from district management capacitation on PMDT (including communication systems and referral links between levels of care, MDR-TB clinical training for decentralised and primary health care staff (including infection control, side effects, defaulter and contact tracing), regular reviews of TB and DR-TB programmes, and integration of TB services into primary health care teams. Conclusions: The project has contributed to scale up of DR-TB control in South Africa, and shows that with political and stakeholders will districts can work with partners to develop interventions that can make community MDR-TB care a reality.

Figure 1: A conceptual framework of the key factors impacting on the intervention using a systems perspective