Finding the Missing Patients With Tuberculosis Lessons Learned From Patient-Pathway Analyses in 5 Countries

• Published in: The Journal of infectious diseases Vol. 216; no. suppl_7; pp. S686 - S695
• Main Authors: Hanson, Christy, Osberg, Mike, Brown, Jessie, Durham, George, Chin, Daniel P.
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 06-11-2017
• Subjects: Community Health Services; Critical Pathways; Delivery of Health Care - statistics & numerical data; Ethiopia - epidemiology; Health Facilities; Humans; Indonesia - epidemiology; Kenya - epidemiology; Pakistan - epidemiology; Patient Acceptance of Health Care; Patient Care; Philippines - epidemiology; Private Sector; Public Sector; Supplement; SUPPLEMENT ARTICLES; Tuberculosis - diagnosis; Tuberculosis - epidemiology; Tuberculosis - prevention & control; Tuberculosis - therapy; Tuberculosis, Pulmonary - diagnosis; Tuberculosis, Pulmonary - epidemiology; patient-pathway analysis; Tuberculosis; private sector; care seeking
• ISSN: 0022-1899; 1537-6613
• DOI: 10.1093/infdis/jix388

Abstract
Background
Despite significant progress in diagnosis and treatment of tuberculosis over the past 2 decades, millions of patients with tuberculosis go unreported every year. The patient-pathway analysis (PPA) is designed to assess the alignment between tuberculosis care-seeking patterns and the availability of tuberculosis services. The PPA can help programs understand where they might find the missing patients with tuberculosis.
Methods
This analysis aggregates and compares the PPAs from case studies in Kenya, Ethiopia, Indonesia, the Philippines, and Pakistan.
Results
Across the 5 countries, 24% of patients with tuberculosis initiated care seeking in a facility with tuberculosis diagnostic capacity. Forty-two percent of patients sought care at level 0 facilities, where there was generally no tuberculosis diagnostic capacity; another 42% of patients sought care at level 1 facilities, of which 39% had diagnostic capacity. Sixty-six percent of patients initially sought care in private facilities, which had considerably less tuberculosis diagnostic capacity than public facilities; only 7% of notified cases were from the private sector. The GeneXpert system was available in 14%–41% of level 2 facilities in the 3 countries for which there were data. Tuberculosis treatment capacity tracked closely with the availability of diagnostic capacity. There were substantial subnational differences in care-seeking patterns and service availability.
Discussion
The PPA can be a valuable planning and programming tool to ensure that diagnostic and treatment services are available to patients where they seek care. Patient-centered care will require closing the diagnostic gap and engaging the private sector. Extensive subnational differences in patient pathways to care call for differentiated approaches to patient-centered care.