Facilitators to community TB program implementation and sustainability.

Input performance measure. Policies and standard operating procedures. This study has noted the existence and availability of policies and Standard Operating Procedures (SOP’s) with clear job descriptions, monitoring, and evaluation components. These documents supported the implementation of community TB because there were rules and regulations guiding service delivery.

The following observation was made.

“The facilities had national TB program policies and SOP’s with description of the role and tasks to be performed by community health workers, treatment supporters and health systems perspectives were clearly documented,”

–(TB clinic Observation 14^th April 2022)

This was further corroborated by one of the interviewees, however she felt the program’s implementation may be hampered by policy omission of age and educational background criterion to determine eligibility of treatment supporters. The following is her recorded opinion.

“The SOP’s and policy are good but do not capture age and educational requirements for eligibility to be a treatment supporter, a younger treatment supporter may seem awkwardness to a patient posing challenge to DOT supervision whereas educational level governs the ability for one to read drugs and dosages thus influencing DOT and documentation”

- (IDI, Nurse, Moshupa health post)

External stakeholders/partnerships. The Moshupa District Management Team (DHMT) collaborated with the United States (U.S.) government through the PEPFAR-funded Botswana University of Maryland School of Medicine Health Initiative (Bummhi), The alliance offers technical support, which contributes to a decrease in TB-related morbidity and mortality.

A health worker asserted:

“The Moshupa village has partnered with (Bummhi) in provision of technical support including patient follow-up. The partnership partially counterbalances TB staff inadequacy in the district, which reduces TB-related morbidity and mortality”.

- (IDI, TB Coordinator).

Similarly, another health worker opined that the collaboration facilitates program implementation, as some key metrics have improved over the years since their inception. The following quote reflect her opinion.

“Even though epidemic control has not yet been achieved, key measurements, such as numbers of people developing TB and numbers of people with TB-HIV co-infection have improved over the years”.

–(IDI, TB focal person)

Performance outputs. Empowerment. The findings reflect that, successful implementation of community-centered TB care depended heavily on community empowerment. Most respondents asserted that community leadership was active, and based on their observations, there were no documented unfavorable opinions of the services offered by CHWs.

A community leader stated that;

“The community was consulted, I remember I was in village development committees (VDC) then when the health education assistants were moving around the community taking care of patients, and the program has no conflict with the community sociocultural practices or believes”.

- (FGD with Community leader)

Similarly, another community leader opined that:

“The community was consulted, I was one of those who were in the red cross, we would take medications on behalf of patients who were not able to carry out their daily activities, and deliver them at their homes”

- (FGD with Community leader)

A health care worker concurred that stakeholders are engaged in implementation, which led to one health care worker admitting that;

“The target population and community leaders are engaged in implementation, but more can still be done by involving them in development of the framework or implementation model”

- (IDI, TB coordinator)

Barriers to community TB program implementation and sustainability.

Input. Program funding. Participants underscored that the program’s objectives were frequently unattainable because of unsustainable TB funding, which has been cited as a challenge to program execution.

A health worker opined that;

“The DHMT relies on government budget to provide for TB services which is often inadequate to fulfill the program activities thus making it difficult to design the program long-term maintenance and monitoring plans with confidence.”

–(IDI, TB coordinator)

This was corroborated by another health worker who felt lack of funding is an obstacle to TB elimination.

“The programme needs more support but there is a challenge of lack of funds to procure all resources needed.”

- (IDI, Medical officer)

Management information systems. The lack of electronic community-based information management systems was viewed as a barrier for CHWs in recording home visits, submitting visit-related data to the health system, and connecting it to an evaluation of their performance. Inconsistencies in stored data, largely due to the use of paper-based tools that potentially compromise the security and privacy of the data, have been reported. An interviewee points out that;

“We do not have any framework of software that facilitates the collection, storage, organization, and distribution of information. Instead, we use patient cards and file them as hard copies, report visit related data is given subjectively to the focal person or coordinator for action.”

–(SSI, Treatment supporter, Mma-Seetsele clinic)

This was further substantiated by an observation that;

“Patients’ information was stored in paper files with some prints no longer visible, some torn”

- (TB Registers Observation 13^th April 2022)

Logistics. Interviewees emphasized the importance of logistics in community TB care and the availability of transport arrangements for CHWs and commodities (equipment, medicines, and supplies). We grouped these factors into two subcategories, as illustrated below.

Transport. Participants expressed that transport was mostly unavailable for community health workers (CHW) to physically access the target population or provisions, either in the form of monetary re-imbursement (fare for buses) or physical (bicycle) for treatment supporters to access health facilities, thus a barrier to TB service delivery.

An interviewee asserted;

“We do encounter transport issues in our line of duty trying to assist our patients, only if we could be assisted with some transport money to board a taxi to collect patient medications and transport them for their reviews would help.”

–(SSI, Treatment supporter, Moshupa SDA)

Similarly, another interviewee stated that;

“Sometimes resources are limited for example lack transport to access TB patients at their homesteads thus impacting negatively on patient management, maybe if our government can consider reimbursement to treatment supporters so that whenever we don’t have transport, they can board taxis to bring the patient to health facility as per necessity.”

–(IDI, Nurse, Moshupa health post)

Commodities (equipment, medicines, and supplies). Respondents reported often being disappointed by the lack of required commodities in equipment, medicines, and supplies to deliver TB services or support the quality of services. Underlining the need for the availability of commodities to facilitate TB program implementation. A participant asserted that;

“There is shortage of sputum induction machines, shortage of medications and there is also shortage of materials e.g, files and cards, thus we lose patient information.”

–(IDI, TB screener, BUMMHI)

Similarly, another health worker opined that:

“Sometimes resources are limited, for example TB cards are often not enough, If we can ensure availability of such commodities we can be able to improve TB management.”

–(IDI, Nurse, Mma-Seetsele clinic)

This concurred with a community leader who commented that:

“We do encounter a shortage of medication at times and some tests are often omitted because of lack of machines to conduct those tests.”

- (FGD with Community leader)

Programmatic processes. We identified two main themes: supportive systems(supervision), and community health worker development (training and incentives). These categories are further illustrated as follows.

Supportive systems (Supervision). Participants expressed a lack of consistent and continued support for problem-solving service delivery and skill development from the program coordinators, primarily due to staffing shortages. This has emerged as a barrier to program implementation because of its potential to affect community health workers’ motivation for their work. This is substantiated by the words of the participant pointing out that;

“There is one TB focal person who also works on shift in outpatient department, when she is not there the program services suffer including supervision of community health worker as there will be no one to oversee the program with other unit staff members engaged with their assignments.”

- (IDI, Data support officer, BUMMHI)

In addition, this was corroborated by another interviewee who opined that;

“In our facility, workers are willing to be involved in TB care but there is no support/supervision from DHMT and TB coordinator, this lack of supervision leads to poor morale thus hesitancy to give their all in TB and its management.”

–(IDI, Nurse, Moshupa health Post)

Community health worker development. Interviewees emphasized the importance of community health worker development in community TB care, recruitment, training, and incentives. We grouped these factors into three sub-categories.

Recruitment. Participants expressed dissatisfaction with the method of identifying, selecting, and onboarding community health workers, citing random selection as opposed to their desire to work in TB programs. This has been identified as impeding program success because workers lose their motivation.

An interviewee asserted:

“Facility staff recruitment in TB care, eg TB focal person is not based on interest but rather unit task allocation potentially leading to unmotivated TB care employees who in turn do very little in delivery of TB services thus impacting the program negatively.”

–(IDI, Nurse, Moshupa health post)

Similarly, one health worker expressed her dissatisfaction citing that;

“Treatment supporter selection is based on patient preferences, no consideration of other engagements such as working, this often leads to supporters leaving patients with medication to take on their own.”

–(SSI, Treatment supporter, Moshupa health post)

Training. Inadequate TB training was portrayed as an important challenge faced by the programme. For example, a few participants reported a lack of trained personnel to deliver TB care, mostly due to lack of funds and failure of those trained to orientate new staff, thus challenging program implementation.

A health worker stated that;

“The TB training is limited due to funds unavailability and staff that has been trained not orientating the new staff. This hampers TB progress to national strategy targets”

–(IDI, TB coordinator)

This was substantiated by another interviewee who opined that;

“I was never trained nor given proper coaching concerning the supervision of TB patients, I just self-taught myself on how a TB patient is taken care of.”

–(SSI, Treatment supporter, Moshupa SDA)

Incentives. Community TB implementation has been hindered by a lack of CHW incentives. Participants emphasized that a lack of monetary and non-monetary rewards tied to performance could have an impact on provider motivation and performance.

A treatment supporter emphasized that:

“My wish is that we can be assisted with food because the socio-economic status is often low, and we don’t have money since we not working anywhere.”

–(SSI, Treatment supporter, Mma- Seetsele clinic)

Although relying on unpaid volunteers appears to make community DOT cheaper, its effectiveness is threatened by volunteerism, as an interviewee points out:

“There is lack of incentives for treatment supporters hence it becomes difficult to enroll patients who stay alone.”

–(IDI, TB coordinator)

Similarly, another health worker opined that;

“Incentives like monetary allowances to treatment supporters can help motivate treatment supporters thus increase cure rates and reduce stigma to TB patients.”

–(IDI, Nurse, Mma-Seetsele clinic)

Performance outputs. Service quality. Interviewees expounded that service quality is a barrier to community TB care sustainability, with the majority reporting low DOT supervision by treatment supporters. The likelihood of poor adherence to DOT standards and procedures by treatment supporters was associated with a lack of training and incentives.

An interviewee pointed out;

“Family members (Adherence buddy) tend to leave clients alone with medication without monitoring them hence clients defaulting treatment.”

–(IDI, Nurse, Moshupa health post)

This is corroborated by another interviewee who said;

“I would explain to the patient how to take medication, because I would leave them with him to take when I’m not there because he knew the tablets.”

–(SSI, Treatment supporter, Mma-Seetsele clinic)

Data reporting. Data reporting also emerged as a barrier to community TB programs, with participants expressing irregularity and incompleteness of CHW reports on the services they provide at the community level.

A health worker stated that;

“There is poor coordination between the doctor and the TB focal person as patients’ information is mostly not comprehensively documented on patients’ cards when the patient is initiated by the doctors e.g. contacts often not captured and the final treatment outcome is most of the time absent in the registries.”

–(IDI, Data support officer, BUMMHI)

This concurs with an observation that;

“TB registers and patient facility cards had missing/incomplete data in almost all facilities eg monthly compliance with treatment, sputum smear results and treatment outcomes data missing.”

-(Registers Observation,13^th April 2022)

Job satisfaction and motivation. Interviewees acknowledged reluctance to put forth and maintain effort on assigned TB activities, gaining less personal gratification from giving back to the community, providing services, and identifying a lack of motivation and reward as major hurdles to the program’s execution.

An interviewee opined that;

“I wish to be the change agent and improve TB patients’ quality of lives in our community however being a treatment supporter is a lot of unpaid work, worse than that there is less support from family and health facility making work even more difficult therefore I don’t think I can risk myself when I’m not happy.”

(SSI, Treatment supporter, Moshupa health post)

Staff retention. Staff attrition was identified as a potential obstacle to program implementation. Few participants addressed the fact that many practicing CHWs had resigned, retired, or given up their jobs, possibly due to a lack of motivation and incentives, consequently making treatment supporters inactive and negatively harming the program. An interviewee points out;

“Treatment supporters are no longer active, with a smaller number of staff trained on TB case management transferred out of the DHMT, and resigning treatment supporter thus crippling the program.”

- (IDI, Nurse, Moshupa SDA)

Community access. Accessibility of TB services in the community has been cited as a hindrance to program implementation. Participants noted that clients did not often seek out or use promotional, preventative, or curative services, possibly due to a lack of knowledge.

An interviewee stated that.

“CTBC uptake is very low mainly due to patients not being interested in the program and health care workers not educating and counselling clients thoroughly on the program.”

–(IDI, TB coordinator)

Other health workers submitted that;

“Care givers are not co-operating with patients and health care workers as they often do not take medication well on time for their patients.)

- (IDI, TB screener, BUMMHI)

“There is poor community involvement as most clients(patients) and care givers are reluctant to enroll on community TB care.”

–(IDI, Medical officer)

Credibility. Implementing the program was hindered by patients’ lack of trust in community health workers. As an interviewee opined that;

“Some families felt we came to assess how they live or judge them when we go on family visit and that created some challenge in delivering the TB services”

- (IDI, TB screener, BUMMHI))

One former red cross volunteer mentioned that patients preferred receiving care from nurses and doctors rather than from treatment supporters, because they had doubts or trust issues and believed that nurses are the ones who could give them quality, respectful care. As an interviewee points out;

“Patients preferred nurses over us as the NGOs and doubted the quality of service we can provide.”

–(FGD with Community leader)