Roll-out and scale-up of who-endorsed technologies for tuberculosis diagnosis in Africa: Opportunities, strengths, and challenges

Abstract

Introduction: Tuberculosis (TB) remains a major public health challenge in the WHO African Region, with high morbidity and mortality, particularly among people living with HIV and those affected by multidrug-resistant TB (MDR-TB). In response, the World Health Organization (WHO) has endorsed several diagnostic technologies to improve TB detection. However, the pace of roll-out and scale-up of these technologies across Africa has been uneven. This thesis aims to assess the implementation status of WHO-endorsed TB diagnostics, identify factors influencing their uptake, and propose a practical guide for integration of TB laboratory services into broader health system responses. Methods: A mixed-methods approach was employed. First, a literature review was conducted to assess the uptake of WHO-endorsed TB diagnostics between 2007 and 2017 and implemented up to 2021 across 47 WHO African Region (WHO/AFR) countries. Second, a structured survey was distributed to National TB Programme (NTP) and National TB Reference Laboratory (NTRL) managers, as well as technical partners, to identify predisposing, enabling, and need (PEN) factors influencing uptake. Finally, lessons learned from TB diagnostic services during recent pandemics were synthesized to develop a practical guide to increase the uptake and rollout in the scope of integrated disease diagnosis. Results: Objective 1: The literature review revealed that uptake of technologies such as Xpert MTB/RIF, Line Probe Assay (LPA), and Mycobacteria Growth Indicator Tube (MGIT) was slow, with median adoption times ranging from 2.5 to 6-9 years respectively. Objective 2: Survey responses from 47 of countries highlighted that laboratory preparedness, staff competence, and policy reform were key predisposing factors; funding availability was the main enabling factor; and the emergence of MDR-TB was the primary need factor. Objective 3: Good governance and political commitment emerged as critical factors. As a key output, the proposed Guide for the Rapid Uptake and Rollout of Tuberculosis Diagnostics in Africa consolidates good practices and lessons learned from the objective 1 and 2, including insights from fieldwork during the COVID-19 pandemic and other emergency disease outbreaks. This guide is designed to support member states in leveraging TB diagnostics to strengthen broader laboratory systems. It also promotes collaboration with the Supranational Reference laboratory Network and other regionally driven laboratory initiatives to catalyze in-country TB laboratory networks, moving towards integrated diagnosis of multiple diseases. Conclusion: Despite WHO endorsement, the roll-out and scale-up of TB diagnostic technologies in Africa have been delayed by systemic and contextual barriers. Addressing PEN factors and leveraging existing TB laboratory networks can accelerate implementation. The proposed guide offers a strategic direction for integrating TB diagnostics into broader disease surveillance and response systems, enhancing preparedness for future health emergencies.