Tuberculosis in South Africa

How to strengthen STOP Tuberculosis (TB) strategic plan in the Orange district (South
Africa)?
This question meets Robsons criteria of a good question because of various reasons.
(Robson, 2002) Firstly, this issue is substantively relevant in the scenario of Orange
district. The burden of tuberculosis (TB) is not only in the district it is rather a national
problem. For instance, TB accounts for one of the leading causes of death in South
Africa. (Wilson et al., 2011) It is also the second cause of mortality in the province. The
number of deaths caused by TB is increasing in the country as well in Orange district. In
contrast to other provinces, the death caused by TB has increased recently in the
district. One of the examples is that Xolani hospital (in Orange District) had the highest
multi drug resistant TB (MDR TB) in the province in 3rd quarter of 2012.
The question is answerable because the majority of the TB cases is curable. The studies
have found that diagnosing TB earlier and providing effective treatment can save lives
as well as prevent transmission of the infection (Wilson et al., 2011). Rifampicin-based
anti-TB drug is available freely at the primary care clinic in accordance with World Health
Organization (WHO) guidelines. Most of the TB burden can be cured or prevented with
known or affordable technologies. The common factors contributing to TB are getting
drugs, vaccines, preventive education, care and treatment on time (WHO, 2007). Most of
which are achievable.
The question is complex as well as interconnected with various sectors. Lack of
adequate health professionals in the clinic/hospital can be associated with a lot of things
such as national health policy document, retention of personnel in the health facility or
uncoordinated mobilization of health personnel within the health system. It is also not
easy to understand how the doctor left his work after being involved in disciplinary
action. A lot of factors would be responsible for nurses frustration at work. Furthermore,
understanding how all non-governmental organizations (NGOs) working in the district to
prevent TB is a complex phenomenon, particularly because of the nature of each
organization. They probably have different interest to gain.
The question raised here is a Macro level question as TB is the most urgent public
health issue in South Africa. (Wilson et al., 2011) Moreover, it is responsible for the
leading cause of death in the country. The government introduced STOP TB strategy not
only to stop TB, but also to alleviate poverty and to provide equitable access to services.
The situation of STOP TB strategy in Orange district is possibly the example only. We
can assume that other districts are probably undergoing the similar conditions. So, this
study can work as a model to understand the problem in the depth and it can bring the
appropriate measures to address in the national level.
The purpose of the question is a combination of descriptive, explanatory,
emancipatory?? Firstly, we need to describe the situation of TB in the district with
respect to the number of cases present, the number of health personnel available, the
quality of the care, the motivation level of the nurses. This gives us a gap present in the
system. A cross-sectional study can be conducted. Then, we try to find out why there are
very few nurses working in TB unit. What is the reason for lack of motivation among
medical officers and nurses? Why is district Communicable Disease Control (CDC)
manager and Primary Health Care (PHC) supervisor did not take any action before the
situation got worse? A couple of case studies or in-depth interview can be done to
explore more. Finally, based on all the finding of descriptive and explanatory study, we
identify the weak point of the system and suggest for the possible remedies which can
be useful in broader context.
Question 2
Why are the nurses working for TB program frustrated in their work in Orange District?
The question is substantively relevant considering the fact that nurses are the key in TB
prevention program. They have a lot of responsibilities such as providing care to the
patients in the clinic, referring the patients to the medical doctors, keeping record of all
the data and supervising community health workers (CHWs). However, they are not
motivated in their work. On one hand nurses have overload of patients on the other
hand, they are often criticized for their work instead of appraisals. As a result, they are
frustrated. Orange district is probably the example only. Other districts are possibly
having the similar issues regarding TB nurses.
The question is answerable. For instance, the number of nurses working for TB
programme can be increased; work responsibilities among health workers can be
distributed. Financial or psychological concerns of the nurses, if any, can be improved.
And nurses are also assigned to do double data entry out of their precious working hours
because each program needs the data in their format, which could easily be improved.
The issue is much more complex and interconnected than it looks like. Senior authorities
have sent few nurses for professional training by underestimating the work load in the
clinic. Sometimes, two nurses are seeing even more than 80 clients a day. A lot training
sessions are being conducted in an uncoordinated manner, leading even fewer nurses at
work for particular time. As there is poor communication and support from the doctors in
TB unit, there is none to guide them in complex drug regimen especially with HIV clients.
So, there are many factors contributing towards nurses frustration at work.
The question is also clear and specific.
This is a micro level question as it involves primarily nurses as individuals. However, as
we mentioned earlier, it is a multi-factorial issue. The question aims to understand many
questions regarding nurses; their knowledge, beliefs, motivation level, clinical skills and
any other hidden issues which are related to TB care delivery. It is noticeable that nurses
are directly working with Tb clients. So, anything affecting the nurses is affecting the TB
clients too.
The purpose of the question is mainly descriptive and exploratory. It is descriptive in a
sense that we need to establish certain facts first. For example, how many nurses in the
district, how many patients per nurse, what is their working hours and pay like? How are
the referral procedures? A cross-sectional study with a couple of case studies involving
in depth interview and focus group discussions (FGD) might be a useful tool to do. Then,
we would like to explore the little known issue of their expectations. What do they think
about the best solution of the crisis? Is it to do with more training or pay rise or
something else?
Question 3
What is the role of actors to achieve STOP TB strategic plan in Orange District?
The question follows Robsons criteria of a good question because its clear, specific,
answerable, interconnected and substantively relevant (Robson, 2002). This is
substantively relevant because of the following reasons. As we see from the scenario, a
lot of actors are involved in the TB program. Yet, the program has been in the downside.
Provincial Minister, Communicable Disease Control (CDC) manager, primary health care
(PHC) supervisors, head of TB services in the hospital and many Non-Governmental
Organizations (NGOs) are few to mention. And there is a national TB strategic plan as a
policy which highlights need of skilled human resources. The question raised is that are
all these actors involved are coordinating to achieve the same goal?
The question is addressable. It is not too ambitious to aim to reduce TB burden, is it?
There is need to discover the role of each actor and their contribution towards the TB
program. Another question to answer is why none of the actors did nothing to prevent TB
burden before it was too late. Doctors are so over-burden with their clinical work they do
not have time for supervision, monitoring and evaluation. TB data were sent to the
district office, bypassing the hospital by hiding the figure of each clinic. Can these simple
things not be rectified?
Certainly, the issue is interconnected with various sectors. For instance, what will justify
allocation of only two medical officers and limited number of nurses in a district which
has the highest amount of TB case loads in the province? What policy are we using to
send nurses for professional training leaving very few in the clinic? In addition, existing
nurses are attending a lot of training instead of clinical work. As a result, TB clients are
seen by any random personnel available at the particular time irrespective of their
clinical skill. Similarly, community health workers (CHWs) are pulled by various programs
nobody knows on what basis. What are the objectives of each NGO towards TB
prevention and care?
This question is meso level as it is mainly in the organizational level. This is the issue of
intermediates who work between national and public level. TB is being used as a tracer
to understand the relationships between various partners involved.
The purpose of the study is mainly exploratory involving partly descriptive. We would like
to explore the power dynamics in reference to TB program. For example, CDC manager
was aware the data register was not prepared by nurses and it had a lot of wrong
information. However, no actions were taken concerning the problem. We will try to
explore in what basis CHWs are selected for particular programs. Descriptive study is
probably needed to find out how many actors involved and what is their position in
reference to TB program? There is also a need of exploring doctors disciplinary action;
why and how was it taken? How will we deal with a lot of complaints raised? Do we need
to review the existing treatment protocol? The probable study designs are a combination
of cross-sectional, document review, semi structured interviews and case studies.
Bibliography
ROBSON, C. 2002. Real World Research: A resource for social scientists and
practitioner researchers. 2nd Edition ed.
WHO 2007. Everybodys business: Strengthening health systems to improve health
outcomes : WHOs framework for action. Geneva: World Health Organization.
WILSON, D., HOWELL, V., TOPPOZINI, C., DONG, K., CLARK, M. & HURTADO, R.
2011. Against all odds: diagnosing tuberculosis in South Africa. J Infect Dis, 204 Suppl
4, S1102-9

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Essays, UK. (November 2013). Tuberculosis In South Africa. Retrieved from
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