Table 2 The contribution of the EXIT-TB Package

Increased TB case detection

Use of X-Ray services

The main contribution of EXIT-TB was improved case identification. Before the project, the facility was identifying less than 50 cases in a year. But when EXIT- TB came, for the first time we were able to find more than 100 cases in one year. So active systematic TB symptoms screening improved case identification, especially within the EXIT-TB project. We were able to diagnose more patients through the use of X-rays as both a screening and diagnostic tool. This is because EXIT-TB was supporting free X-Ray services, especially among those who couldn’t afford them. [The project] was paying for the X-rays. So, you're able to diagnose more TB cases, even using X-rays, something that we were not able to do before EXIT-TB (Clinician, Uganda)

Engagement of CHWs

Working with [CHWs] facilitated the smooth implementation of the EXIT- TB programme by helping patients who were in the programme to get the right services at the right time and reduce costs. It was cost-effective for the patients. They received the right services from the time they entered the facility beginning with health education provided to them to increase their confidence in the TB screening process…those who were found to have TB were immediately put on medications and followed up (Clinical Officer, Tanzania)

Increased community awareness and linkage

One of our responsibilities was to make the community members know and understand the existence of TB in the community. Awareness raising was effective in the catchment area because if someone goes to the community today and asks questions about TB people will be able to answer. We did not only teach them about the existence of the disease but also how the disease is transmitted, how to prevent it and where to go for treatment. We conducted symptoms screening and referred symptomatic patients for further investigation. In the course of the investigation, we were able to find patients who are TB positive and directed them to treatment (CHW, Uganda)

HCWs support to CHWs

Healthcare workers provided support and guidance to us. We were free to move to different departments. Providers prioritised us and gave us an opportunity to talk to patients and we were given a priority to see clinicians (CHWs, Kenya)

Screening infrastructure

We used to do TB Screening and triage at OPD, but it was just an open space. Then when EXIT-TB came in, we realised that we need more space with partitions for specific tasks. We, therefore, created three partitions, one for screening, one for coughing patients and another one for registering new patients, and then we have the other one for HIV screening (Nursing Officer, Uganda)

New screening criteria and training

EXIT-TB came up with a different approach from the existing national guideline. For example, the national guideline considered coughs of fourteen days or more as a proxy for TB screening. However, with the exit TB project implementation, this practice was changed and anyone with a cough of any duration was screened. This new practice facilitated early detection. The screening was also mandatory for newly diagnosed HIV patients, those in stage 3 and 4 patients. Patients with cough of any duration were screened and sent to clinicians for further evaluation and diagnosis. Whenever a patient presented with any TB symptom it was a must to be screened and this was very decisive and facilitated early detection and reduced patient suffering. Previously, patients were referred to the laboratory for diagnosis at a very late stage…after developing the disease and after they became very ill. However, this project accepted patients even those without a single symptom especially those with HIV stage 3 or stage 4… they were all screened and diagnosed (TB Focal Person, Ethiopia)

Reduced delays in TB Care

Speedful screening, sample collection and processing, and results provision

One of the good things we started was giving priority to patients with coughs. Previously they were treated with other patients. The other thing is that there was no cough clinic at the beginning, but it was established during the time of the EXIT TB project and enabled us to isolate coughing patients from other clients. Isolated clients got early treatment (ART Head, Ethiopia)

Whenever we went to the hospital, we were screened quickly for TB infection, sent to the doctor and samples taken quickly. If the result is negative, we were told about the precautions that we must take and in case someone tests positive, they put to start the medications right away (EXIT-TB patient, Uganda)

Improved capacity and decision-making among HCWs

Training, co-learning and peer mentorship

Through this study, we got more knowledge, and we met our TB targets because during that time TB was a problem. People did not have adequate knowledge about TB and especially in the entire area and even within the hospital. some did not have enough knowledge… even our staff within the hospital didn’t have enough knowledge about TB. Most of these staff got experience as they were implementing Exit-TB, and we used to have CMEs which further strengthened their knowledge of TB, how it is transmitted and how to screen. We were able to sensitise them, give them knowledge in their different departments, and mentored and supervised them. Before the project, we were getting a small number of TB clients but when EXIT- TB came, we were able to increase the number of TB clients… (TB Clinic Focal Person, Uganda)

Reduced Lost to follow-up clients

Strong contact management systems, referral system, engagement of TB focal persons and link assistants

We were able to increase our TB case identification by around 30% or more because of the contact management that we put in place. We were able to identify other cases from the community, especially children and refer them to the facility. That is another one. Also, we were able to minimise the issues of lost clients because once the client comes into the system, we were able to closely follow up through the engagement of the TB focal person. If the client has not reported to the facility, then we will report to TB focal person and link assistants who conducted defaulter management activities. I think we only lost one case throughout the project compared to previous years where we would lose up to four cases. The lost client was an extreme case because a client committed a legal offence and ran away. We exhausted all efforts to contact him unsuccessfully. Reduced lost clients increased our treatment success rates (Clinical Officer, Kenya)