A health systems assessment of the KwaZulu-Natal tuberculosis programme in the context of increasing drug resistance

Int J Tuberc Lung Dis. 2008 Sep;12(9):1042-7.


Setting: High mortality and high transmission rates of extensively drug-resistant tuberculosis (XDR-TB) in KwaZulu-Natal Province of South Africa have highlighted the role of hospitals in the spread of TB and drug-resistant TB.

Objectives: To determine the operational effectiveness of the National TB Programme (NTP) at a regional/district hospital and its referral clinics.

Design: In this multi-faceted retrospective case study, a framework was developed to evaluate the different components of the TB services, their performance in relation to each other and the system as a whole. Different methods used included structured and semi-structured interviews, retrospective medical record reviews and retrospective register reviews.

Results: Only 18% of those diagnosed with smear-positive pulmonary TB (PTB) in the hospital laboratory completed their treatment and 11% were cured. Clinicians did not adhere to the diagnostic guidelines of the NTP. In the TB register, 85% of PTB cases were diagnosed in the absence of sputum microscopy. Chest X-rays alone were used to diagnose PTB in 45% of the records reviewed. In addition, clinicians failed to document a clinical history suggestive of TB. Only 66 (29%) of the hospital's 225 smear-positive PTB patients reached the clinics for completion of their treatment.

Conclusion: System failures, together with inadequate knowledge and understanding of clinicians, undermined the effectiveness of the NTP. A reduction in TB and drug-resistant forms of TB is dependent on effective diagnosis, treatment and improved communication systems between the hospital, laboratory and its down-referral clinics.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antitubercular Agents / therapeutic use
  • Delivery of Health Care / organization & administration*
  • Extensively Drug-Resistant Tuberculosis / diagnosis
  • Extensively Drug-Resistant Tuberculosis / drug therapy*
  • Health Knowledge, Attitudes, Practice
  • Humans
  • Medical Records
  • National Health Programs / organization & administration*
  • Operations Research
  • Patient Dropouts
  • Referral and Consultation / organization & administration*
  • Referral and Consultation / statistics & numerical data
  • Registries
  • Retrospective Studies
  • South Africa
  • Tuberculosis, Multidrug-Resistant / diagnosis
  • Tuberculosis, Multidrug-Resistant / drug therapy


  • Antitubercular Agents