'Power plays plus push': experts' insights into the development and implementation of active tuberculosis case-finding policies globally, a qualitative study.

Olivia Biermann,Salla Atkins,Kerri Viney,Maxine Caws,Knut Lönnroth

doi:10.1136/bmjopen-2019-036285

Abstract

ObjectiveTo explore experts’ views on factors influencing national and global active case-finding (ACF) policy development and implementation, and the use of evidence in these processes.DesignThis is an exploratory study based on semistructured expert interviews. Framework analysis was applied.ParticipantsThe study involved a purposive sample of 39 experts from international, non-governmental and non-profit organisations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide.ResultsThis study highlighted the perceived need among experts for different types of evidence for ACF policy development and implementation, and for stakeholder engagement including researchers and policymakers to foster evidence use. Interviewees stressed the influence of government, donor and non-governmental stakeholders in ACF policy development. Such key stakeholders also influence ACF policy implementation, in addition to available systems and processes in a given health system, and implementers’ motivation and incentives. According to the interviewees, the World Health Organization (WHO) guidelines for systematic screening face the innate challenge of providing guidance to countries across the broad area of ACF in terms of target groups, settings and screening algorithms. The guidelines could be improved by focusing on what should be done rather than what can be done in ACF, and by providing howto examples. Leadership, integration into health systems and long-term financing are key for ACF to be sustainable.ConclusionsWe provide new insights into ACF policy processes globally, particularly regarding facilitators for and barriers to ACF policy development, evidence need and use, and donor organisations’ influence. According to expert participants, national and global ACF policy development and implementation can be improved by broadening stakeholder engagement. Meanwhile, using diverse evidence to inform ACF policy development and implementation could mitigate the ‘power plays plus push’ that might otherwise disrupt and mislead these policy processes.

Highlights

Tuberculosis (TB) is a major global health emergency, especially in low- and middle- income countries
In low- and middle- income countries, the interest in active case-finding (ACF) has increased in recent years, mainly as a response to a sustained case detection gap documented in TB prevalence surveys, annual Global TB Reports produced by WHO1 and the development of new World Health Organization (WHO) guidelines on systematic screening.[9]
We generated the following themes from the data: (1) evidence generation and use, (2) factors influencing ACF policy development, (3) factors influencing ACF policy implementation, (4) WHO guidelines on systematic screening, and (5) sustainability of ACF

Summary

Introduction

Tuberculosis (TB) is a major global health emergency, especially in low- and middle- income countries. Still, it remains the leading cause of death from a single infectious agent and one of the top 10 causes of death worldwide.[1] In 2019, the estimated incident TB cases and those notified globally resulted in a difference of 3 million cases, reflecting a combination of under-reporting of detected TB cases and underdiagnosis, in countries with major financial and geographic barriers to accessing care.[1] Many people with TB are diagnosed only after long delays,[2,3,4] causing increased morbidity, much suffering and economic hardship, and sustaining transmission.[1].

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Conclusion