Preparedness of outpatient health facilities for ambulatory treatment with all-oral short DR-TB treatment regimens in Zhytomyr, Ukraine: a cross-sectional study

Abstract

Background Ukraine has a high burden of drug-resistant tuberculosis (DR-TB). Mental health problems, including alcohol use disorder, are common co-morbidities. One in five DR-TB patients has human immunodeficiency virus (HIV). As part of health reform, the country is moving from inpatient care to ambulatory primary care for tuberculosis (TB). In Zhytomyr oblast, Médecins Sans Frontières (MSF) is supporting care for DR-TB patients on all-oral short DR-TB regimens. This study describes the preparedness of ambulatory care facilities in Zhytomyr oblast, Ukraine, to provide good quality ambulatory care. Methods This is a retrospective analysis of routinely collected programme data. Before discharge of every patient from the hospital, MSF teams assess services available at outpatient facilities using a standardised questionnaire. The assessment evaluates access, human resources, availability of medicines, infection control measures, laboratory and diagnostic services, and psychosocial support. Results We visited 68 outpatient facilities in 22 districts between June 2018 and September 2019. Twenty-seven health posts, 24 TB-units, 13 ambulatories, two family doctors and one polyclinic, serving 30% of DR-TB patients in the oblast by September 2019, were included. All facilities provided directly observed treatment, but only seven (10%) provided weekend-services. All facilities had at least one medical staff member, but TB-training was insufficient and mostly limited to TB-doctors. TB-treatment and adequate storage space were available in all facilities, but only five (8%) had ancillary medicines. HIV-positive patients had to visit a separate facility to access HIV-care. Personal protective equipment was unavailable in 32 (55%) facilities. Basic laboratory services were available in TB-units, but only four (17%) performed audiometry. Only ten (42%) TB-units had psychosocial support available, and nine (38%) offered psychiatric support. Conclusion Outpatient facilities in Zhytomyr oblast are not yet prepared to provide comprehensive care for DR-TB patients. Capacity of all facilities needs strengthening with trainings, infection control measures and infrastructure. Integration of psychosocial services, treatment of co-morbidities and adverse events at the same facility are essential for successful decentralisation. The health reform is an opportunity to establish quality, patient-centred care.

Shifting Stigma: Why Ukrainian Health Care Workers Favor a High Barrier Treatment Modality for Tuberculosis

“…However, as of the writing of this article (May 2022) this second wave of reforms affecting specialised healthcare delivery has still not been implemented. In addition to the enormous challenges posed by Russian military aggression in Ukraine, efforts by Ukraine's Ministry of Health to shift the general standard of TB care from inpatient to ambulatory treatment continues to be hindered by numerous systemic factors: insufficient healthcare staff and infrastructures for managing outpatient care; extremely low salaries for TB specialists that limit motivation for change; national TB plans that fail to elaborate financial or implementation strategies; and organised resistance from healthcare professionals against proposed reforms (Davtyan et al 2019;Gils et al 2020;Nading 2021).…”

“…Much international development aid directed at Ukraine's TB control systems in recent years has focused on strengthening laboratory standards for TB diagnosis but relaxing the strict inpatient treatment protocols that have defined TB care in Ukraine since the Soviet era (Chemonics International, Inc. 2017). Despite recent changes in national policy, TB care in Ukraine has long consisted-and largely continues to consist-of hospitalisation for months or years, followed by yet another lengthy outpatient phase (Gils et al 2020). This lengthy hospitalisation negates the flexibility and self-determination that the WHO claims are integral for treatment success.…”