Low case detection rate of tuberculosis in Ziarat : how the target will be achieved?

Background Pakistan is ranked 8th in the 22 high tuberculosis burden countries. The incidence and prevalence of TB are estimated to be 297,000 per year and 365,000 per year respectively. The disease is causing an estimated 48,000 deaths per year in the country. The DOTS strategy was introduced in 1995 in Pakistan and 100% DOTS coverage was achieved in 2005 in the country. Pakistan achieved 70% Case detection Rate in 2008 and 85% Treatment Success rate in 2006. DOTS program was initiated in 2004 in district Ziarat in four diagnostic centers for TB. The district has never achieved the target of 70% CDR and it is lowest in the province since beginning. Mercy Corps under the European Commission TB project has worked along with government sector for three years to improve the CDR. Despite the combined efforts of government and MC the CDR has not been improved and there is lack of evidence based research to guide the policy makers to improve the situation. This study explore all the factors influencing the CDR of TB at various levels (at community level, among health providers and at health care system level) by in-depth interviews and FGDs and find the issues in identifying the TB suspects and gaps in referral of suspects through HMIS and TB registers review for the past five years. Methodology This mixed method study was conducted in District Ziarat. The concurrent triangulation study design was used. Data was collected through in-depth interviews, focus group discussions and document review. Study participants were selected through purposive sampling strategy. Thirteen interviews were conducted with TB patients, health care providers and different key informants. Four focus group discussions were held with Lady Health Workers. Qualitative analysis was done manually. A checklist was used to review the HMIS and TB registers and descriptive analysis was done. Ethical approval was taken from Ethical review committee of the Aga Khan University. Results The descriptive analysis shows that the suspect identification and suspect positivity rate of the district are very low. The true suspect identification rate could not be identified due to non availability of HMIS registers in the facilities while the suspect positivity rate was only 5% in the district. The qualitative analysis shows that most of the TB suspects are prompt in seeking health care for the disease in the public health facilities but despite multiple encounters they are not diagnosed in time. Most of the LHWs and laboratory technicians are trained but majority of the doctors providing DOTS services are not trained for TB DOTS. The role of LHWs, private GPs and BHUs in suspect identification and referral to diagnostic centers is very negligible. Staff deficiency and absenteeism was also found to be associated with low CDR. Due to non diagnosis at health facilities in Ziarat most of the patients are being diagnosed in Quetta. Access to health care facilities, cost of treatment and stigma related was not associated with low CDR. Conclusion Factors related to health system level are more responsible than the patient related factors for low CDR of TB in district Ziarat. Creating community awareness, improving human resource and referral system and engaging private practitioners are vital for increasing the CDR. Small scale prevalence survey in district Ziarat will further inform policy makers to develop strategies to overcome the problem