Jassat W, Moshabela M, Nicol M P, Dickson L, Cox H, Mlisana K, Black J, Loveday M, Grant A D, Kielmann K, Schneider H
TB Control and Management Cluster, National Department of Health, Pretoria, South Africa.
Genesis Analytics, Johannesburg, South Africa.
Public Health Action. 2025 Sep 3;15(3):97-102. doi: 10.5588/pha.25.0004. eCollection 2025 Sep.
A policy of decentralised care for drug-resistant TB (DR-TB) was introduced in South Africa in 2011. We describe a trade-off between increasing coverage of services and poor quality of care, in the early phase of policy implementation.
This was a mixed methods case study, comparing implementation in KwaZulu-Natal and Western Cape provinces; with interviews and quantitative analysis of routine DR-TB programme data. We analysed qualitative data, thematically organizing findings into inputs, processes, and outputs to explore how decentralisation influenced quality of DR-TB care.
Decentralisation of DR-TB care expanded access across provinces but there was wide variation in pace, planning and structural readiness. Where rapid scale-up outpaced capacity-building, weaknesses in resourcing, workforce, and clinical governance compromised quality of care. Two illustrative examples highlight that decentralisation to inadequately resourced sites resulted in morbidity to patients who did not receive effective monitoring for adverse events; and decentralising services to inadequately capacitated clinicians resulted in incorrect initiation in more complex cases and late referral of clinical complications.
Attempts to decentralise DR-TB treatment in the context of complex treatment algorithms and limited health system capacity resulted in trade-offs of care quality. We argue that quality of care should be an essential consideration in early implementation of health programmes.
2011年南非引入了耐药结核病（DR-TB）分散式护理政策。我们描述了在政策实施初期，扩大服务覆盖范围与护理质量不佳之间的权衡。
这是一项混合方法的案例研究，比较了夸祖鲁-纳塔尔省和西开普省的实施情况；对耐药结核病常规项目数据进行访谈和定量分析。我们分析了定性数据，将研究结果按主题组织成投入、过程和产出，以探讨分散化如何影响耐药结核病护理质量。
耐药结核病护理的分散化扩大了各省的就医机会，但在速度、规划和结构准备方面存在很大差异。在快速扩大规模超过能力建设的地方，资源、劳动力和临床治理方面的弱点损害了护理质量。两个示例突出表明，将服务分散到资源不足的地点会导致未接受有效不良事件监测的患者发病；而将服务分散给能力不足的临床医生会导致在更复杂的病例中起始治疗不正确以及临床并发症转诊延迟。
在复杂的治疗方案和有限的卫生系统能力背景下，尝试分散耐药结核病治疗导致了护理质量的权衡。我们认为，在卫生项目早期实施中，护理质量应是一个重要考虑因素。
