Interventions for increasing the proportion of health professionals practising in rural and other underserved areas.

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BackgroundThere are significant delays in initiation of multidrug-resistant tuberculosis (MDR –TB) treatment. The Xpert MTB/RIF test has been shown to reduce the time to diagnosis and treatment of MDR-TB predominantly in urban centres. This study describes the time to treatment of MDR-TB and the effect of Xpert MTB/RIF on time to treatment in a deprived rural area in South Africa.MethodsThis was a retrospective cohort study analysing the medical records of patients diagnosed with MDR-TB in King Sabata Dalindyebo Sub-District between 2009 and 2014. Numerical data were reported using the Kruskal-Wallis and Wilcoxon sum rank tests and categorical data compared using the two-sample test of proportions.ResultsOf the 342 patients with MDR-TB identified, 285 were eligible for analysis, of whom 145 (61.4%) were HIV positive. The median time from sputum collection to MDR-TB diagnosis was 27 days (IQR: 2–45) and differed significantly between diagnostic modalities: Xpert MTB/RIF, 1 day (IQR: 1–4; n = 114: p < 0.0001); Line Probe Assay 12 days (IQR: 8–21; n = 28; p < 0.0001); and culture/phenotypic drug sensitivity testing 45 days (IQR: 39–59; n = 143: p < 0.0001). The time from diagnosis to treatment initiation was 14 days (IQR: 8–27) and did not differ significantly between diagnostic modality. The median time from sputum collection to treatment initiation was 49 days (IQR: 20–69) but differed significantly between diagnostic modalities: Xpert MTB/RIF, 18 days (IQR: 11–27; n = 114; p < 0.0001); Line Probe Assay 29 days (IQR: 14.5–53; n = 28; p < 0.0001); and culture/phenotypic drug sensitivity, 64 days (IQR: 50–103; n = 143: P < 0.0001). Age, sex and HIV status did not influence the time intervals.ConclusionsXpert MTB/RIF significantly reduced the time to MDR-TB treatment in a deprived rural setting as a result of a reduced time to diagnosis. However, the national target of five days was not achieved. Further research is needed to explore and address programmatic and patient-related challenges contributing to delayed treatment initiation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-017-2200-8) contains supplementary material, which is available to authorized users.

Despite policies for addressing shortages and maldistribution of health professionals, sub-Saharan Africa continues to experience shortages and maldistribution of skilled health professionals. Policies such as return-of-service schemes or state-funded educational initiatives do not seem to be achieving their intended objectives, potentially due to poor design, implementation; and lack of monitoring and evaluation of the strategies. A focus by global health experts on strengthening and reformulating educational initiatives offers potential for producing, retaining and recruiting health professionals.