Integration of systematic screening for tuberculosis in outpatient departments of urban primary healthcare facilities in Zambia: a case study of Kitwe district.

BACKGROUND: Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, killing about 1.5 million people annually, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shape the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia. METHODS: This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n = 8) and in-depth (n = 15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun's Integration framework. RESULTS: The facilitators to integration of systematic screening for TB into out patient departments of primary health facilities included the perceived high burden TB, compatibility of the systematic screening for TB program with healthcare workers training and working schedules, stakeholder knowledge of each others interest and values, regular performance management and integrated outreach of TB screening services. Constraining factors to integration of systematic screening for TB into outpatient departments included complexity of screening for TB in children, unbalanced incentivization mechanisms, ownership and legitimacy of the TB screening program, negative health worker attitudes, social cultural misconceptions of TB and societal stigma as well as the COVID-19 pandemic. CONCLUSION: Systematic screening of TB is not fully integrated into the primary healthcare facilities in Zambia to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB program to local needs and capacities as well as strengthening the health system.

Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia.

BACKGROUND: Saving Mothers, Giving Life (SMGL) significantly reduced maternal and perinatal mortality in Uganda and Zambia by using a district health systems strengthening approach to address the key delays women and newborns face in receiving quality, timely, and appropriate medical care. This article documents the transition of SMGL from pilot to scale in Uganda and Zambia and analyzes the sustainability of the approach, examining the likelihood of maintaining positive trends in maternal and newborn health in both countries. METHODS: We analyzed the potential sustainment of SMGL achievements using a tool adapted from the HIV-focused domains and elements of the U.S. President's Emergency Plan for AIDS Relief Sustainability Index and Dashboard for maternal and neonatal health pro-gramming adding a domain on community normative change. Information for each of the 5 resulting domains was drawn from SMGL and non-SMGL reports, individual stakeholder interviews, and group discussions. FINDINGS: In both Uganda and Zambia, the SMGL proof-of-concept phase catalyzed commitment to saving mothers and newborns and a renewed belief that significant change is possible. Increased leadership and accountability for maternal and newborn health, particularly at the district and facility levels, was bolstered by routine maternal death surveillance reviews that engaged a wide range of local leadership. The SMGL district-strengthening model was found to be cost-effective with cost of death averted estimated at US$177-206 per year of life gained. When further considering the ripple effect that saving a mother has on child survival and the household economy, the value of SMGL increases. Ministries of health and donor agencies have already demonstrated a willingness to pay this amount per year of life for other programs, such as HIV and AIDS. CONCLUSION: As SMGL scaled up in both Uganda and Zambia, the intentional integration of SMGL interventions into host country systems, alignment with other large-scale programs, and planned reductions in annual SMGL funding all contributed to increasing host government ownership of the interventions and set the SMGL approach on a path more likely to be sustained following the close of the initiative. Lessons from the learning districts resulted in increased efficiency in allocation of resources for maternal and newborn health, better use of strategic information, improved management capacities, and increased community engagement.