Standardized Patients: An approach to understanding the realities of South Africa's TB care cascade
While most tuberculosis (TB) programs are concerned about coverage, relatively little attention has been paid to quality of TB care. Poor quality of TB care increases risk of death, transmission and drug-resistance. South Africa has the highest rate of TB incidence worldwide, with 834 cases per 100,000 of its population. In 2015, 65% of 454,000 estimated new cases of TB were notified to the South African National TB Program (SANTP); remaining cases were not notified.
Data on cascade of care for patients with TB, multidrug-resistant TB (MDR-TB) and TB-HIV show major gaps in quality of care for these synergistic epidemics in SA. Acknowledging this, the NDOH, supported by BMGF and partners, are embarking on a Quality Improvement (QI) program within the public system. Treatment for TB is freely available through the public health sector in South Africa, and non-public providers are required to refer potential TB patients to the public sector (Skordis-Worrall, Hanson et al. 2010). A 11 country patient pathways analysis by BMGF showed that nearly a third of South Africans seek initial care outside the public system (graphic below). Global systematic reviews show that an initial visit to a private provider or traditional healers is associated with significant TB diagnostic delay. Studies also suggest that about 70% of black people in South Africa use traditional health practitioners (THPs) in one way or another (Ross et al S Afr J Bioeth Law. 2010; Zuma et al. BMC Comp Alt Med 2016).
Studies that have explored private provider practices in SA suggest that diagnostic delays are greater among patients who initially visit a private provider, and private providers are less likely to order sputum tests (Meintjes, Schoeman et al. 2008, Van Wyk, Enarson et al. 2011). Taken together, these findings suggest there may be a major gap in the capacity of private providers to achieve early TB case detection and refer patients for appropriate treatment and care within the public sector. South African patients are also known to practice pluralistic behaviours, with frequent visits to providers in the public and private sectors as well as THPs before TB diagnosis and during TB treatment (Meintjes, Schoeman et al. 2008, Skordis-Worrall, Hanson et al. 2010). In particular, certain populations are known to use traditional healers, known as sangomas, when they become ill. Thus far, no studies have empirically explored how private formal doctors and THPs manage cases of presumptive TB or manage TB patients who return to private care after initiating treatment in the public sector. Previous studies have associated patient visits to THPs with delays in accessing TB therapy (Barker 2006), and also found low levels of referral to biomedical health care providers (Peltzer, 2006). More recently the efforts have been made to formally integrate THPs into the formal processes of managing TB as part of engaging all care providers.