Filling Gaps in TB Service Delivery

Worldwide, tuberculosis (TB) is the leading cause of death from infectious disease, surpassing even HIV, according to a 2014 World Health Organization report. As the lead agency for the U.S. Government TB response, USAID works with its partners to save lives and prevent the spread of the disease. The USG TB Strategy calls for improving overall health systems crucial to the effort to improve TB control in 23 priority countries.

USAID’s Health Finance and Governance (HFG) project plays a role in the USG TB response through several programs and activities. HFG’s TB programs focus on (1) improving TB service delivery through more effective and efficient payment of TB care providers, (2) speeding up the TB diagnostic process, and (3) working with ministries of health to increase their human resources and budgeting with attention to TB care.

Incentivizing Effective and Efficient TB Care

Even when doctors and nurses are trained to provide TB care, and lab tests and drugs are made available by donors, patients do not always receive the best possible care. Often, public financial management (PFM) systems contain barriers that impede the effective purchasing and provision of TB services from care to treatment, resulting in poorer health outcomes for the most vulnerable populations. The concrete results may include cases of TB left unrecognized if providers are not incentivized to screen for it or high levels of drug resistance as a result of improperly implemented treatment regimes.

HFG works to improve the effectiveness and efficiency of TB service provision by identifying and recommending small improvements in TB purchasing/provider payment and related PFM to better target country health budgets towards priority TB services for the poor in USAID TB priority countries.

Hard copy files on cases treated in TB hospitals in Poltava Oblast are all being entered into a database as part of new payment system development.

Hard copy files on cases treated in TB hospitals in Poltava Oblast are all being entered into a database as part of new payment system development.

In Kyrgyzstan, where over-hospitalization is the norm for TB care, HFG has helped the government transition to a more efficient output-based payment system for TB hospitals, based on diagnosis-related groups (DRGs). By paying TB hospitals more money to treat contagious or difficult-to-treat drug resistant cases and less for simpler cases, the new TB hospital payment system  helps shift patients to WHO-recommended fully outpatient treatment, wherever possible.

The new DRG system is expected to save USD $1 million in the first year of full implementation. The new payment system has served as a catalyst for development of a national “road map” for TB system restructuring—closure of extraneous hospitals, and shifting funding and specialized staff to primary health facilities for outpatient TB treatment. HFG and the national working group handed the DRG system over to Kyrgyzstan’s State Mandatory Health Insurance Fund for national implementation in August 2015.

Building on the Kyrgyzstan experience, HFG is developing DRGs for in-patient TB care in Poltava Oblast in central Ukraine, with planned expansion to additional regions in the country, toward more effective and efficient TB care. WHO and other international partners have expressed interest in further disseminating the HFG TB hospital payment model to other countries in the region.

READ: Kyrgyzstan Modernizes TB Hospital Financing

Supervisors using smartphone for supportive supervision at LGA facility.

Supervisors using smartphone for supportive supervision at LGA facility.


TB testing and results reporting can be a lengthy process in countries that lack access or the means to purchase the newest and best technologies. Drug-resistant TB (DR-TB) is difficult and expensive to treat, and is often fatal, especially in circumstances of delayed diagnosis. Identifying drug-resistant strains, enrolling patients in treatment programs, and testing their contacts in a timely manner is critical to epidemic control.

In Nigeria, HFG is supporting the national response to TB programming by improving the diagnosis and treatment of TB through improved supportive supervision at the local government level. HFG is supporting the National Tuberculosis and Leprosy Control Programme (NTBLCP) in installing and implementing an innovative, mobile-based solution in 46 laboratories across the country. The GxAlert software integrates with the automated diagnostic GeneXpert machines to drastically shorten the diagnostic reporting period. This system helps provide reliable, real-time data for strategic decision making.

READ: Partnering with Nigeria to Adopt Technology for Rapid TB Response
and Nigerians Scale Up Smartphones to Diagnose, Treat TB

Increasing Resources: Budgets and Health Workers

To tackle its substantial TB burden, South Africa continues to rapidly scale up its response, dramatically increasing financing for TB programs over the past decade. Rapid scale-up requires credible resource needs estimates to inform budget allocations. In partnership with the Government of South Africa (GOSA) National Treasury, the HFG project conducted an intensive analysis of TB data and budgeting. Informed by HFG’s analysis, the National Treasury’s proposal increasing allocations for TB was approved by the South African Cabinet in October 2015. South Africa has budgeted an additional USD $19 million in 2017/18 and USD $40 million  in 2018/19 for expanding TB interventions, including active case finding, improved diagnostics, and chemoprophylaxis for people living with HIV and other high-risk groups. HFG played an important support role in enabling these successes.

READ: Additional Domestic Resources to Scale-Up the HIV and TB Response in South Africa

With the world’s highest prevalence of TB/HIV co-infection (80 percent of TB patients have HIV), Swaziland has a critical need for a well-trained and sustainable workforce of medical professionals. As the country works to build and retain its health workforce, the Ministry of Health has recognized the need to oversee the quality of health services being provided. To enhance the Swaziland Nursing Council (SNC)’s regulatory capacity, HFG supported the development of entry-to-practice competencies for nurses and midwives, with a separate domain dedicated to the treatment of HIV, AIDS, TB and DR-TB. The competencies are helping Swaziland bolster health worker capacity to provide TB care and treatment, and help fill its gap in TB care.

READ: Swaziland: Entry-to-Practice Competencies for Nurses to Improve HIV, TB Services

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