By Upama Khatri, MPH
TB DIAH, working with the TB team at USAID Washington, is using the Quality of TB Services Assessment (QTSA) methodology and tools to evaluate the quality of TB services in randomly selected health facilities in priority high-burden TB countries. In early 2020, TB DIAH began customizing the QTSA protocol and tools to the Afghanistan TB context in preparation for implementing the QTSA in Afghanistan. In the middle of this process, Afghanistan, suddenly facing an unprecedented COVID-19 pandemic with the rapid worldwide spread of the virus, chose to use the QTSA to also assess the effects of COVID-19 on TB services.
COVID-19 caused immediate concerns about the impact of additional stress on an already overburdened health system and the disruption to basic health services. Social distancing measures and lockdowns meant fewer people screened for and diagnosed with TB and those who were already on TB treatment facing difficulties obtaining their medications. These challenges can lead to decreased adherence, increased treatment failure, increased drug resistance, and other adverse outcomes.
When the COVID-19 pandemic began, TB DIAH was already working with Afghanistan’s national TB program to adapt and contextualize the four standard QTSA tools – the facility audit, register review, provider interview, and patient interview – and developing two Afghanistan-specific tools – the community health worker and TB focal point interview to be used at prison health centers and facilities and the diabetes center health interview to be administered to outpatient department clinicians responsible for checking diabetic patients. Then, reports emerged of the collateral damage that COVID-19 was causing to the TB program. From an individual patient perspective to the global perspective, decades of progress in the fight to end TB were reversed in a matter of months.
The USAID mission in Afghanistan expressed an interest in including questions in the QTSA to assess how the COVID-19 response is affecting the quality of TB services in Afghanistan. TB DIAH, aided by an in-country consultant, met with the mission to clearly understand the data needs and started drafting COVID-19 modules to add to the facility audit and the patient interview tools. The new questions in the facility audit are geared towards assessing the degree to which COVID-19 has affected the delivery of various screening, diagnosis, treatment, and support services; whether the facility has reallocated resources from TB services to COVID-19; and if and how case detection and treatment management have been impacted. A short module was also added to the patient interview to obtain the patient’s perspective on how COVID-19 has affected their ability to access TB services.
The COVID-19 modules for these two tools were shared with the national tuberculosis program and the Global Fund in Afghanistan for review and feedback. The complete set of QTSA tools have been pretested, and data collectors are expected to be in the field in December 2020. This data will provide insight into the effects of COVID-19 on TB in Afghanistan and help inform the responses of decision makers.