India has established the foundations of a system to transform the quality of its tuberculosis care. Now, the country needs to adopt a new system that helps India's national TB programme quickly identify real-time challenges and implement risk mitigation strategies. Improving the quality of TB care services in India will be the magic bullet against the disease
Ending tuberculosis (TB) is an important global priority today. The first-ever United Nations General Assembly High-Level Meeting on TB was convened on September 26 where heads of states and representatives of states made key commitments towards ending the disease. We now stand at a crucial moment in TB history as we approach the targets set within the Sustainable Development Goals and the global mandate for expansion of universal health coverage.
One of the challenges with achieving these goals lies in diagnosing and treating patients accurately and efficiently. This is particularly pertinent for India where 4.45 per cent of deaths in the country are attributed to the disease (Global Health Data Exchange, 2016). Studies indicate that in India, only 60 per cent of TB patients are successfully diagnosed, 45 per cent complete treatment, and 39 per cent achieve recurrence-free survival. (Subbaraman R, Nathavitharana RR, Satyanarayana S, Pai M, Thomas BE, The Tuberculosis Cascade of Care in India's Public Sector: A Systematic Review and Meta-analysis. PLOS Medicine)
India has recently made great strides in access to and coverage of evidence-based TB services to reduce losses along the cascade of care. The Joint Effort for Elimination of Tuberculosis (JEET) project, for example, which will cover 45 cities and 406 districts, aims to amplify TB care coverage by connecting patients in the private sector with free-of-cost treatment and benefits available under the national TB programme and standardising treatment protocols in the private sector. Also, since 2013, through the Initiative for Promoting Affordable and Quality TB Tests (IPAQT), private sector diagnostic labs are providing WHO-endorsed TB tests at substantially reduced prices, which would otherwise be unaffordable for a large section of the population.
While access and coverage are foundations of a high-quality health system, achieving improved health outcomes also requires a focus on improving processes of care. India's new National Strategic Plan does envisage the implementation of certain Quality Improvement systems for TB care, however, studies have pointed out that processes of TB care (i.e., extent to which patients receive recommended care) in India in both the public and private sector fall short of national and international standards. (Quality of tuberculosis care in high burden countries: the urgent need to address gaps in the care cascade, International Journal of Infectious Diseases, Volume 56, 2017, Pages 111-116, ISSN 1201-9712)
Fortunately, well-established methods to monitor and improve processes of care exist and are easily adapted to the Indian context. Quality Improvement methods were first introduced in the 1920s to reduce variation in manufacturing processes and thereby produce a consistent product. These methods evolved further and were applied with great success to the automotive industry, particularly by companies like Toyota in Japan, in the 1980s and have since become established in nearly every industry, including healthcare. At its basic core, Quality Improvement involves the use of facility-level data by front-line providers to drive continuous process improvement. For example, the Model for Improvement which embraces the Shewhart Cycle, commonly known as Plan-Do-Study-Act (PDSA) is a common Quality Improvement framework in which a team of health workers develops an aim, identify changes to test in their system, implement those that are successful, and then assess their impact on the predefined performance measures. The cycle is repeated continuously to achieve and sustain high-quality care.
Nascent Quality Improvement efforts related to TB care are now being reported around the world. Studies in Uganda have shown that quality indicators of TB care can be measured using data routinely collected in TB registers and used to drive performance improvement. South Africa recently became the first country to develop and implement a formal TB Quality Improvement programme on a national scale. The latter requires the national TB programme to lead the development of a formal Quality Management Plan that establishes a technical working group or committee, a set of core performance measures, expectations for implementing Quality Improvement activities, plans for staff capacity building and patient/community involvement.
These elements of governance, which include national monitoring of core measures, are necessary to sustain the health system's focus on quality in the face of environmental changes that affect the stability of healthcare organisations and the workforce. (Bardfield J, Palumbo M, Geis M, Jasmin M, Agins B. A National Organizational Assessment (NOA) to Build Sustainable Quality Management Programs in Low- and Middle-Income Countries)
Such a system would help India's national TB programme quickly identify real-time challenges and implement risk mitigation strategies. To test the efficacy of this system in improving programmatic outcomes, the TB programme can consider piloting it in selected sites across the country.
A fundamental concept of improvement is that every system is perfectly designed to achieve exactly the results it achieves. Comprehensive Quality Improvement systems will be vital to perfecting India's national TB programme and ensuring that every TB patient successfully completes treatment. India has established the foundations of a system to transform the quality of its TB care. Now, all that is left for the country is to implement change.
(Dr Adithya Cattamanchi is an Associate Professor of Medicine and co-Director of the Implementation Science Training Program at the University of California San Francisco. Dr Bruce Agins is the Director of HEALTHQUAL International and Professor of Epidemiology at the University of California San Francisco, Institute for Global Health Sciences)