The effects of decentralisation on patient and service outcomes: a case of the 2018 decentralisation of multidrug-resistant tuberculosis in Zambia.

Introduction: The Zambian government decentralised tuberculosis control programs by transferring responsibility for the care and treatment of multidrug-resistant tuberculosis (MDR-TB) patients from a two-national hospital model to provincial hospitals and other lower-level healthcare structures. Limited evidence exists on the effects of decentralisation on the quality of TB care provided through public sector decentralisation. In this paper, we explored the impact of decentralising MDR-TB on patient and service outcomes.

Methods: This study used a mixed-methods approach. Quantitative data were collected through a survey of 244 MDR-TB patients, while qualitative data was collected through interviews with TB coordinators, healthcare providers, patients, and caregivers. Participants were drawn from health facilities and the Ministry of Health. Quantitative data was analysed in STATA version 16.0, while thematic analysis was used for the qualitative data.

Results: Decentralisation has improved patient care and management by increasing access to essential commodities such as medication and diagnostic testing. It has led to more equitable distribution of MDR-TB healthcare services and resources across different population groups, regardless of social, economic, or demographic factors. Furthermore, the quality of life for MDR-TB patients has improved, with better adherence to medication resulting from increased family support. Due to decentralisation, tailored community and patient-centred services have been integrated resulting in reduced congestion at facilities. The study also identified challenges, including heavy workload for healthcare staff, fragmented coordination of supervisory responsibilities, and confusion over roles in patient management, which negatively impacted the decentralisation process.

Conclusion: The decentralisation of MDR TB services offers significant benefits but is not a guaranteed solution, as poor planning or implementation can lead to challenges in service delivery.