Revisions in TB programme - boon or bane? A qualitative study exploring barriers and facilitators among health care workers in private and public sector, Kerala

Abstract

Background: Despite many serious and organized efforts worldwide, Tuberculosis (TB) remains one of the major public health concerns in many countries. India accounts for more than one quarter of global TB cases and deaths each year. India's National Tuberculosis Elimination Programme (NTEP) is the largest TB control program in the world, placing more than 100,000 patients on treatment every month. There have been so many revisions in the programme guidelines in the last 5 years. As we are gearing up for TB elimination in India, knowledge regarding the barriers is very crucial in the successful undertaking of these revised guidelines. Exploring perceptions of health care workers, both from the private and public sector will help to design appropriate strategies at the field level.

Objective: To explore the barriers and facilitators among health care workers in the implementation of revised NTEP guidelines in a selected district of central Kerala.

Methodology: This qualitative study was conducted among health care workers from all levels involved in the implementation of NTEP from private and public sector. Qualitative data was collected through Focus Group Discussions (FGD) and Key Informant Interviews using a topic guide till data saturation. All discussions were audio recorded with the consent of participants. Sociogram was plotted to confirm equal participation of interviewees. A total of 4 FGDs (2 from each sector) and 12 Key informant interviews (7 from public sector and 5 from private sector) were conducted after obtaining written consent from the participants.

Results: Overall awareness about revisions was found to be good. However, the study identified a "Gap between planners and implementers". Frequent nature of revisions without understanding the practical difficulties in the field, additional job responsibilities, inadequate knowledge among grass root level workers/private practioners in small clinics and increased side effects were the major barriers identified. In addition to that, insufficient logistics, not enthusiastic in learning revisions, fear of losing patients, delay in communication, decreased compliance with new regimen, increased out of pocket expenditure and grey areas in the current guidelines were also adversely affecting the successful implementation At the same time, facilitators like positive attitude and commitment of health care workers, introduction of M-health technology, strong public private partnership, inclusion of costly investigations in the revised guidelines, good administrative support, financial assistance, innovative initiatives like Treatment Support Groups (TSGs) and concept of Family Directly Observed Treatment Short-Course increased the effectiveness of the programme to a large extent.

Conclusion: The study identified gaps in knowledge, attitude and practice of revised guidelines at the field level. Gap between 'Planners and implementers could impede the successful implementation of TB Elimination programme and needs to be addressed.

Keywords: Barriers; Facilitators; Health care workers; Kerala; Revisions in TB.