Addressing healthcare system barriers to timely initiation of tuberculosis treatment: A case review of the Uganda National TB Program

Michael Juma, The University of Texas School of Public Health


Background: Efforts to reduce Tuberculosis (TB) incidence and improve patient outcomes should result in an increase in the number of cases identified as well as a reduction in the period between onset of symptoms and initiation of treatment. We examined Uganda’s existing TB treatment policy for opportunities to eliminate process delays and patient loss to follow up during the care process. Methods: We reviewed Uganda’s TB treatment policy to examine the existing TB care flow process map for weaknesses leading to delays or discontinuation of care from patient registration up to dispensing of treatment. We then proposed an improved process flow map that incorporates solutions to each of the identified weaknesses. Findings: Tuberculosis care was provided as part of the primary healthcare services package. Steps for identifying suspected TB cases, conducting and reporting laboratory tests, and initiating treatment were standardized with simplified decision making, favoring wide scale adoption. Systematic screening was done at patient registration to improve efficiency in the identification of presumptive TB cases. The recommended approach to establishing a TB diagnosis was sputum microscopy requiring two specimens submitted over a two-day period, which minimized missed diagnoses where the first specimen was negative. However, the resulting increase in workload and hence personnel, time and supplies costs could potentially prolong results turnaround time if not well matched by available resources and good laboratory practices. Patients faced high travel expenses and opportunity costs making multiple visits before treatment initiation. There was no consistent communication among personnel, and between personnel and patients. Data in tracking efficiency of systems within a healthcare facility including follow up of patients with critical results was not emphasized. Conclusion: Revisiting existing care processes is important in reducing TB incidence and improving outcomes of patients with the disease in Uganda. A care flow process that maintains systematic symptom screening followed by testing of two specimens in the day of a patient’s initial clinic visit could significantly reduce delays and loss of patients to follow up. Records reconciliation is important to accurately track efforts to improve timeliness of TB treatment.

Subject Area

African Studies|Public health|Epidemiology|Health care management

Recommended Citation

Juma, Michael, "Addressing healthcare system barriers to timely initiation of tuberculosis treatment: A case review of the Uganda National TB Program" (2015). Texas Medical Center Dissertations (via ProQuest). AAI10027726.