Global-to-local policy transfer in the introduction of new molecular tuberculosis diagnostics in South Africa

Rapid molecular tests for tuberculosis and tuberculosis drug resistance: a qualitative evidence synthesis of recipient and provider views

BACKGROUND

Programmes that introduce rapid molecular tests for tuberculosis and tuberculosis drug resistance aim to bring tests closer to the community, and thereby cut delay in diagnosis, ensure early treatment, and improve health outcomes, as well as overcome problems with poor laboratory infrastructure and inadequately trained personnel. Yet, diagnostic technologies only have an impact if they are put to use in a correct and timely manner. Views of the intended beneficiaries are important in uptake of diagnostics, and their effective use also depends on those implementing testing programmes, including providers, laboratory professionals, and staff in health ministries. Otherwise, there is a risk these technologies will not fit their intended use and setting, cannot be made to work and scale up, and are not used by, or not accessible to, those in need.

OBJECTIVES

To synthesize end-user and professional user perspectives and experiences with low-complexity nucleic acid amplification tests (NAATs) for detection of tuberculosis and tuberculosis drug resistance; and to identify implications for effective implementation and health equity.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, PsycInfo and Science Citation Index Expanded databases for eligible studies from 1 January 2007 up to 20 October 2021. We limited all searches to 2007 onward because the development of Xpert MTB/RIF, the first rapid molecular test in this review, was completed in 2009.

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis, and were focused on perspectives and experiences of users and potential users of low-complexity NAATs to diagnose tuberculosis and drug-resistant tuberculosis. NAATs included Xpert MTB/RIF, Xpert MTB/RIF Ultra, Xpert MTB/XDR, and the Truenat assays. Users were people with presumptive or confirmed tuberculosis and drug-resistant tuberculosis (including multidrug-resistant (MDR-TB)) and their caregivers, healthcare providers, laboratory technicians and managers, and programme officers and staff; and were from any type of health facility and setting globally. MDR-TB is tuberculosis caused by resistance to at least rifampicin and isoniazid, the two most effective first-line drugs used to treat tuberculosis.

DATA COLLECTION AND ANALYSIS

We used a thematic analysis approach for data extraction and synthesis, and assessed confidence in the findings using GRADE CERQual approach. We developed a conceptual framework to illustrate how the findings relate.

MAIN RESULTS

We found 32 studies. All studies were conducted in low- and middle-income countries. Twenty-seven studies were conducted in high-tuberculosis burden countries and 21 studies in high-MDR-TB burden countries. Only one study was from an Eastern European country. While the studies covered a diverse use of low-complexity NAATs, in only a minority of studies was it used as the initial diagnostic test for all people with presumptive tuberculosis. We identified 18 review findings and grouped them into three overarching categories. Critical aspects users value People with tuberculosis valued reaching diagnostic closure with an accurate diagnosis, avoiding diagnostic delays, and keeping diagnostic-associated cost low. Similarly, healthcare providers valued aspects of accuracy and the resulting confidence in low-complexity NAAT results, rapid turnaround times, and keeping cost to people seeking a diagnosis low. In addition, providers valued diversity of sample types (for example, gastric aspirate specimens and stool in children) and drug resistance information. Laboratory professionals appreciated the improved ease of use, ergonomics, and biosafety of low-complexity NAATs compared to sputum microscopy, and increased staff satisfaction. Challenges reported to realizing those values People with tuberculosis and healthcare workers were reluctant to test for tuberculosis (including MDR-TB) due to fears, stigma, or cost concerns. Thus, low-complexity NAAT testing is not implemented with sufficient support or discretion to overcome barriers that are common to other approaches to testing for tuberculosis. Delays were reported at many steps of the diagnostic pathway owing to poor sample quality; difficulties with transporting specimens; lack of sufficient resources; maintenance of low-complexity NAATs; increased workload; inefficient work and patient flows; over-reliance on low-complexity NAAT results in lieu of clinical judgement; and lack of data-driven and inclusive implementation processes. These challenges were reported to lead to underutilization.  Concerns for access and equity The reported concerns included sustainable funding and maintenance and equitable use of resources to access low-complexity NAATs, as well as conflicts of interest between donors and people implementing the tests. Also, lengthy diagnostic delays, underutilization of low-complexity NAATs, lack of tuberculosis diagnostic facilities in the community, and too many eligibility restrictions hampered access to prompt and accurate testing and treatment. This was particularly the case for vulnerable groups, such as children, people with MDR-TB, or people with limited ability to pay. We had high confidence in most of our findings.

AUTHORS' CONCLUSIONS

Low-complexity diagnostics have been presented as a solution to overcome deficiencies in laboratory infrastructure and lack of skilled professionals. This review indicates this is misleading. The lack of infrastructure and human resources undermine the added value new diagnostics of low complexity have for recipients and providers. We had high confidence in the evidence contributing to these review findings. Implementation of new diagnostic technologies, like those considered in this review, will need to tackle the challenges identified in this review including weak infrastructure and systems, and insufficient data on ground level realities prior and during implementation, as well as problems of conflicts of interest in order to ensure equitable use of resources.

How are global health policies transferred to sub-Saharan Africa countries? A systematic critical review of literature

Background

Most sub-Saharan Africa countries adopt global health policies. However, mechanisms with which policy transfers occur have largely been studied amongst developed countries and much less in low- and middle- income countries. The current review sought to contribute to literature in this area by exploring how health policy agendas have been transferred from global to national level in sub-Saharan Africa. This is particularly important in the Sustainable Development Goals (SDGs) era as there are many policy prepositions by global actors to be transferred to national level for example the World Health Organization (WHO) policy principles of health financing reforms that advance Universal Health Coverage (UHC).

Methods

We conducted a critical review of literature following Arksey and O’Malley framework for conducting reviews. We searched EBSCOhost, ProQuest, PubMed, Scopus, Web of Science and Google scholar for articles. We combined the concepts and synonyms of “policy transfer” with those of “sub-Saharan Africa” using Boolean operators in searching databases. Data were analyzed thematically, and results presented narratively.

Results

Nine articles satisfied our eligibility criteria. The predominant policy transfer mechanism in the health sector in sub-Saharan Africa is voluntarism. There are cases of coercion, however, even in the face of coercion, there is usually some level of negotiation. Agency, context and nature of the issue are key influencers in policy transfers. The transfer is likely to be smooth if it is mainly technical and changes are within the confines of a given disease programmatic area. Policies with potential implications on bureaucratic and political status quo are more challenging to transfer.

Conclusion

Policy transfer, irrespective of the mechanism, requires local alignment and appreciation of context by the principal agents, availability of financial resources, a coordination platform and good working relations amongst stakeholders. Potential effects of the policy on the bureaucratic structure and political status are also important during the policy transfer process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00821-9.

Barriers and facilitators to implementing evidence-based health innovations in low- and middle-income countries: A systematic literature review

The unsuccessful implementation of health innovations occurs frequently, leading to missed opportunities where improvements could have been made on various aspects of a health system. The purpose of this study is to identify, assess and synthesise the facilitators and barriers to sustainably implementing evidence-based health innovations in a low- and middle-income country (LMIC) context. To identify the LMIC specific facilitators and barriers, a systematic literature review was conducted. 79 studies were analysed, and the implementation barriers and facilitators identified in each study were extracted. The extracted barriers and facilitators were categorised and synthesized into one of seven concepts: context, innovation, relations and networks, institutions, knowledge, actors or resources. There were no substantial variations between the frequency that each concept was identified as a facilitator or barrier to implementation. However, resources, which includes time, human, financial and physical resources, was the most frequently mentioned concept; emphasising the need to focus on the resource situation in LMICs. This study contributes to the growing literature that aims to inform health system planners and evaluators in LMICs on effectively and sustainably implementing evidence-based health innovations.

What is the relevance of policy transfer and policy translation in integrated care development?

Purpose

The purpose of this paper is to document the influence of policy transfer on integrated care development, its global occurrence and shifts towards integrated care. It highlights the influence of supranational forces, and the roles and relevance of policy transfer and policy translation in the development of integrated care.

Design/methodology/approach

This paper presents the findings of an international review of the policy transfer of integrated care, and the relevance of policy translation in integrated care development.

Findings

The global occurrence in integrated care, as evinced in this paper, can be seen in the global shift towards integrated care in various countries. However, studies exploring the actual mechanism of policy transfer and policy translation in relation to integrated care across countries are limited. The study of integrated care through the lens of policy transfer is important, as it for example, explores the structural elements, including environmental and cognitive obstacles in the policy transfer process. Policy translation offers a social constructivist approach to explore the travel of ideas, and considers the multiple spatial and scalar contexts in which integrated care policy is implemented.

Originality/value

This paper aims to advance policy transfer and policy translation as complementary frameworks to explain integrated care development. Second, it seeks to make novel and useful contributions to the debate about the development of integrated care, and to the wider arguments on policy transfer and policy translation and integrated care in other parts of the world.

MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care

BACKGROUND

South Africa has a high burden of MDR-TB, and to provide accessible treatment the government has introduced different models of care. We report the most cost-effective model after comparing cost per patient successfully treated across 5 models of care: centralized hospital, district hospitals (2), and community-based care through clinics or mobile injection teams.

METHODS

In an observational study five cohorts were followed prospectively. The cost analysis adopted a provider perspective and economic cost per patient successfully treated was calculated based on country protocols and length of treatment per patient per model of care. Logistic regression was used to calculate propensity score weights, to compare pairs of treatment groups, whilst adjusting for baseline imbalances between groups. Propensity score weighted costs and treatment success rates were used in the ICER analysis. Sensitivity analysis focused on varying treatment success and length of hospitalization within each model.

RESULTS

In 1,038 MDR-TB patients 75% were HIV-infected and 56% were successfully treated. The cost per successfully treated patient was 3 to 4.5 times lower in the community-based models with no hospitalization. Overall, the Mobile model was the most cost-effective.

CONCLUSION

Reducing the length of hospitalization and following community-based models of care improves the affordability of MDR-TB treatment without compromising its effectiveness.

Health service perceptions about implementation of a new TB diagnostic in Northern Russia: a qualitative study

Setting: Many tuberculosis services are implementing new diagnostics to accelerate treatment initiation for multidrug-resistant tuberculosis. Successful implementation and uptake are likely to depend on many factors. Objective: To describe the perceptions of the Arkhangelsk health services staff in Northern Russia on the process of introducing the line-probe assay and to determine what facilitates the process of uptake into practice. Design: Process evaluation; semi-structured, in-depth interviews with key informants from civil and penitentiary health services; content analysis. Results: A good working relationship between the civil and penitentiary sectors and a tradition of positive collaboration between doctors and managers were integral to success. Uptake and adaptation were facilitated by regular discussions between managers and implementers, flexibility in adapting routines and an iterative approach to improving procedures. It is beneficial to allow all types of health care workers affected by the diagnostic to learn about it and contribute to its integration. A multidisciplinary evaluation can detect problems elsewhere in the care pathway. Bringing about change in workplace mind-sets and attitudes takes time and management. Conclusion: People take time to observe the effects of innovations, assess relative advantages and become convinced, sometimes by different types of evidence. Multi-disciplinary opportunities for learning, reflecting on care pathways and adaptation should all be a part of introducing new diagnostics.