Practices of diagnosis and treatment of pulmonary tuberculosis, associated factors, barriers and facilitators among private practitioners in Kampala, Uganda

Abstract

Introduction: Globally, tuberculosis (TB) is a leading cause of morbidity and mortality accounting for an estimated 10.0 million new cases and 1.451million deaths in 2018. Uganda is one of the world’s high TB burden countries with an incidence of 234 and a prevalence of 253 per 100000 populations. However, a significant portion of cases are missed each year with only 7.0 million cases notified to national TB programs and reported to the World Health Organization (WHO) in 2018. Sixty-two percent of the 3.6million missing cases in 2017 were in countries with a popular private sector. Uganda is no exception with the private sector accounting for 50% of health outputs and serving 60% of the urban populations. Studies outside Uganda have pointed out suboptimal practices of diagnosis and treatment of TB among private practitioners and a number of factors related to these practices. Though the National TB and Leprosy Program (NTLP) has one of its policies as involvement of private health providers, very few are involved despite them serving a bigger proportion of the population. Objective: To evaluate the practices of diagnosis and treatment of pulmonary tuberculosis, associated factors, barriers and facilitators among practitioners in private for-profit (PFP) clinics and hospitals in Kampala. Methods: It was an explanatory mixed methods study among 630 randomly selected private practitioners in Kampala. A cross sectional design was used for the quantitative study and phenomenological design for the qualitative study. A semi-structured questionnaire and an interview guide were used for data collection. Descriptive statistics, generalized linear models with log Poisson link and content analysis were used to analyze data. Practices were graded as standard or substandard. Results: Only 46.2 (26.6-67.1) % of the private practitioners studied had overall standard practices. Qualification of the practitioner being a laboratory technician (PR=2.729, p-value=< 0.001) or doctor (PR=1.204, p-value=< 0.001), level of qualification being a degree (PR=1.095, p-value=0.021), quarterly supervision by the national TB program (PR=1.339, p-value=0.023), and acceptable knowledge of the practitioner about TB (PR=1.756, p-value<0.001) were significantly associated with standard practices. Barriers included high cost of TB diagnosis in PFPs, high turnover of practitioners, lack of equipment for diagnosis, poor infrastructure and unsafe laboratories, lack of skilled personnel, poor relationship between PFPs and NTLP, TB-related stigma, poor referral systems. Facilitators included utilization of referrals to private laboratories, other PFPs, PNFPs and public facilities. Conclusions: The practices of practitioners from the private for-profit hospitals and clinics in Kampala were much less than they should be with only 46.2% of the practitioners having overall standard practices. With a small proportion of PFPs working with the NTLP which oversees TB care services in the country, it means majority of the population is not being targeted for TB care which frustrates efforts towards end TB 2035. If licensing bodies could work with PFPs to improve the standards of infrastructure and MOH works on improving the working relationship between PFPs and NTLP and supports them to handle TB care services, this can go a long way in ending the burden of TB in the country.