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Project’s support at decentralized sites in O.R. Tambo improves DR-TB patient outcomes

Project’s support at decentralized sites in O.R. Tambo improves DR-TB patient outcomes
Publication date: 
Oct 2020

O.R. Tambo is a rural district located on the coastline to the east of the Eastern Cape Province in South Africa. The district has five sub-districts namely King Sabatha Dalindyebo, Nyandeni, Mhlontlo, Port St Johns and Ingquza Hill. O.R. Tambo’s population is 1 465 533 (Stats SA Community Survey 2016), the largest in the Province accounting for 20% of the entire population of the Eastern Cape Province.  The district has poor infrastructure, not only with regards to road networks but also health systems. The poor infrastructure is part of the reason for the high percentage of unemployment.

In 2016 when the USAID TB South Africa Project started, O.R. Tambo only had four decentralized sites that could manage and care for drug-resistant tuberculosis (DR-TB) patients. These four sites were unevenly distributed in the five sub-districts with two operating in King Sabatha Dalindyebo (Zithulele Hospital and Mthatha Gateway Clinic), one in Nyandeni (St. Barnabas Hospital) and the fourth in Ingquza Hill (Holy Cross Hospital). None of these sites were properly equipped to care for DR-TB patients and seriously ill patients that required specialized DR-TB management were referred to Nkqubela Hospital, a Centre of Excellence, which is about three to six hours’ drive from the decentralized sites. Due to lack of transport, referred patients had to wait for the following day’s hospital transport, and were expected to stay near the decentralized site without accommodation until the transport would depart. These patients had often spent three to four days walking from their homes to the decentralized site in the first place and would often just not manage to reach Nkqubela Hospital. If they did manage to get there they had to travel back for monthly reviews until discharged and due to lack of funds for transport, referred patients were often lost to follow up and died.

The USAID TB South Africa Project, with the Department of Health (DoH), took the initiative to increase the number of decentralized sites to ten so that each sub-district at least had one decentralized site. This would not only improve the accessibility to DR-TB services in the hard-to-reach rural communities but also ensure that patients were closer to their families throughout the treatment journey for support.

To this end, St. Elizabeth Hospital was earmarked as an additional site in Ingquza Hill, three sites in Mhlontlo (Mhlakulo CHC, Dr Malizo Mpehle Memorial Hospital and Nessie Knight Hospital) and two in Port St. Johns (Bambisana Hospital and Isilimela Hospital). The sub district, district and provincial DR-TB units were engaged throughout the process and supported the project’s interventions to strengthen service delivery capacity at all levels.  

Firstly, the project appointed a DR-TB consultant who orientated the staff at the six new sites to conduct baseline assessments and prepare for accreditation. The project then appointed a DR-TB sessional doctor to strengthen the skills of the DoH doctors and their DR-TB teams at the newly established sites. They were couched and mentored to assess DR-TB patients, initiate treatment and to conduct DR-TB patient reviews. The new decentralized sites were accredited to start providing DR-TB services and staff were able to manage DR-TB patients appropriately.

To ensure continuance of care at home, the project’s funded NGOs provide Directly Observed Treatment (DOT) support to DR-TB patients in King Sabatha Dalindyebo, Mhlontlo and Nyandeni sub districts. DOT support improves treatment adherence and ensure patient retention throughout the treatment journey.

The impact of the USAID TB South Africa Project’s efforts to improve decentralization in the district resulted in improved loss to follow up (LTFU) rates, decreased death rates and improved the overall DR-TB patient outcomes.

In the first quarter of 2018 the treatment success rate for DR-TB patients on the short regimen was 40.5% (15/37) and by the first quarter in 2019 it increased to 67% (38/57). The LTFU rate for short regimen did not change much at 24.3% (9/37) in 2018 and 25% (14/57) in 2019, but the death rate has dropped by 14.6% from 21.6% (8/37) in 2018 to 7% (4/7) in 2019. For the long regimen patient outcomes all improved with treatment success at 37.5% (9/24) in quarter 1 of 2017 and at 57% (4/7) in 2019. LTFU rates decreased by 2.7% from 16.7% (4/24) in 2017 to 14% (1/7) in 2018. The death rate also decreased 33.3% (8/24) in 2017 to 14% (1/7) in 2018.

All ten decentralized sites are now fully functional and regular DR-TB audits are being conducted to ensure continuous quality improvement.

This video highlights the USAID TB South Africa’s work towards decentralization in O.R. Tambo: