‘It has become everybody’s business and nobody’s business’: Policy actor perspectives on the implementation of TB infection prevention and control (IPC) policies in South African public sector primary care health facilities

Abstract

South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on 'new' evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like maskwearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.

Using system dynamics modelling to estimate the costs of relaxing health system constraints: a case study of tuberculosis prevention and control interventions in South Africa

“…, 2020 ). Umoya omuhle collected a wealth of information on the policies, norms and values governing TB-IPC processes for clinic staff and patients, as well as on the infrastructure and resources for TB-IPC, implementation challenges, and on existing levels of indoor ventilation and congregation to parametrize a model of Mtb transmission in the clinics and surrounding communities ( Colvin et al. , 2020 ; Mccreesh et al.…”

Organisational Culture and Mask-Wearing Practices for Tuberculosis Infection Prevention and Control among Health Care Workers in Primary Care Facilities in the Western Cape, South Africa: A Qualitative Study

“…Some authors have usefully explored the relationships between aspects of organisational culture, such as leadership, and coordinated change efforts in health facilities and improved implementation of IPC [20,34]. Our participants, along with those in other studies [15,31] have likewise recognised that changes in mask use by opinion leaders within the clinic context could help to create a local cultural norm of mask-wearing.…”

“…In the context of the high TB burden in South Africa, it is not surprising that the risk of TB infection has become 'normalised'. Research on the development of TB-IPC policy in South Africa has described how the pervasiveness of TB triggers a sense of "fatalism" or "toughness" in HCWs and for those who have worked in the field for a long time, a sense of "invulnerability to infection" [31]. This sense of pervasiveness and inevitability can also make TB risk less visible and feel less urgent.…”

Occupational Risk of Airborne Mycobacterium tuberculosis Exposure: A Situational Analysis in a Three-Tier Public Healthcare System in South Africa

“…The discrepancy may be due to a small hospital sample size in this study. TBIPC is an important component in overall TB control efforts within health facilities [ 9 , 42 ]. Our study demonstrated that the use of natural ventilation was variable between the different facilities.…”

“…The likelihood of TB transmission amongst health workers is also influenced by the patient population, type of occupation, regional TB prevalence, medical facility access [ 4 , 38 ], inadequate infrastructure, poor ventilation [ 39 , 40 ], delayed and incorrect diagnosis [ 41 ], and TB infection control programmes’ efficacy [ 4 , 38 , 40 ]. The resource allocation shift to the COVID-19 pandemic also poses a serious threat to the reduction of the global TB detection and notifications, thereby hampering the progress made in recent years [ 42 , 43 , 44 ]. Between January and June 2020, SA was among the four countries that reported a significant decrease in the number of TB-diagnosed people that account for 44% of global TB cases [ 11 ].…”