A Qualitative Exploration into a Statewide Differentiated TB Care Initiative Aimed at Reducing TB Deaths

Background: In April 2022, Tamil Nadu, with 0.1 million annual tuberculosis (TB) notifications, launched Tamil Nadu Kasanoi Erappila Thittam (TN-KET), streamlining the triaging for severe TB at diagnosis and prioritizing comprehensive care and admission within the existing health system. After 1 year, target process indicators related to triaging, referral, and inpatient care were met. TB death rates significantly reduced after two quarters of statewide implementation. To effectively refine the initiative and further accentuate the potential impact, it is essential to explore qualitatively the enablers and barriers in implementing TN-KET and the suggested solutions to overcome them. Methods: This was a descriptive qualitative study. Interviews with experienced TB program staff and people with TB were conducted between June 2022 and November 2023. Descriptive thematic analysis was carried out using ATLAS.ti9 software. Results: The enablers were around optimum utilization of available resources; strategizing action for effective implementation; motivated staff; local initiatives and leadership; reorientation training and regular monitoring. Suboptimal knowledge, especially among non-National TB Elimination Program (NTEP) staff; issues in coordinating with non-NTEP staff; shortage of resources, and negative attitude of providers and family members were the key barriers. Suggested solutions were around quality improvement strategies and health system changes. Conclusion: The identified barriers and proposed solutions can help refine the initiative. Future efforts should prioritize quality triaging, better involvement of non-TB program staff, and support nodal inpatient facility physicians through regular training and untied local funds. A limitation was the lack of detailed insights into isolation beds and therapeutic nutrition.