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PLoS One. 2014 Apr 9;9(4):e94016. doi: 10.1371/journal.pone.0094016. eCollection 2014.

Association between health systems performance and treatment outcomes in patients co-infected with MDR-TB and HIV in KwaZulu-Natal, South Africa: implications for TB programmes.

Author information

Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
Tuberculosis & HIV Investigative Network of KwaZulu-Natal (THINK), Durban, South Africa.
Retired from Centres for Disease Control and Prevention, Atlanta, Georgia, United States of America.
Department of Medicine, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York, United States of America.
KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa.
King Dinuzulu Hospital Complex, KwaZulu-Natal Department of Health, Durban, South Africa.
Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.



To improve the treatment of MDR-TB and HIV co-infected patients, we investigated the relationship between health system performance and patient treatment outcomes at 4 decentralised MDR-TB sites.


In this mixed methods case study which included prospective comparative data, we measured health system performance using a framework of domains comprising key health service components. Using Pearson Product Moment Correlation coefficients we quantified the direction and magnitude of the association between health system performance and MDR-TB treatment outcomes. Qualitative data from participant observation and interviews analysed using systematic text condensation (STC) complemented our quantitative findings.


We found significant differences in treatment outcomes across the sites with successful outcomes varying from 72% at Site 1 to 52% at Site 4 (p<0.01). Health systems performance scores also varied considerably across the sites. Our findings suggest there is a correlation between treatment outcomes and overall health system performance which is significant (r = 0.99, p<0.01), with Site 1 having the highest number of successful treatment outcomes and the highest health system performance. Although the 'integration' domain, which measured integration of MDR-TB services into existing services appeared to have the strongest association with successful treatment outcomes (r = 0.99, p<0.01), qualitative data indicated that the 'context' domain influenced the other domains.


We suggest that there is an association between treatment outcomes and health system performance. The chance of treatment success is greater if decentralised MDR-TB services are integrated into existing services. To optimise successful treatment outcomes, regular monitoring and support are needed at a district, facility and individual level to ensure the local context is supportive of new programmes and implementation is according to guidelines.

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