Evaluating TB diagnosis and care in the Union of the Comoros

SETTING: The Union of the Comoros has experienced a persistent notification gap in TB cases despite several strategic changes, including molecular diagnosis and contact investigation. We therefore performed a TB patient pathway analysis (PPA) under the National Tuberculosis Programme (NTP). OBJECTIVE: To assess the alignment of healthcare-seeking behaviour and TB service availability to clarify the reasons for these missing cases. DESIGN: Three primary data sources, including a national list of health facilities, TB surveillance data and care-seeking behaviour data, were analysed at the national and regional levels to determine access to TB diagnosis and the initial point of care-seeking. Summary data were visualised using the standardised PPA Wizard programme, and the analysis was completed using demographic and socio-economic data. RESULTS: At the initial point of care-seeking, 18% of patients had access to TB services, available only in nine centralised public health facilities. Furthermore, 30% of patients initially consulted in the informal sector and 45% in the formal public or private sector in health facilities, both of which lacked the capacity for TB diagnosis or first-line treatment. CONCLUSION: The concentration of and limited access to TB services at the intermediate and central levels of care indicate a need for decentralisation efforts.