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Improving the quality of tuberculosis care in the post-pandemic world

In 2019, recognizing the importance of quality in TB care, the Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, launched a series on this topic [1]. The series included 19 published papers [2–20], and covered a diverse range of topics. The entire series is open access and available at: https://www.sciencedirect.com/journal/journal-of-c linical-tuberculosis-and-other-mycobacterial-diseases/special-issue/10 JL8LN0VVT. In this concluding article, we cover the key messages from papers in the series. We also outline some strategies for improving quality of TB care. Given the Covid-19 pandemic and its negative impact on TB services, the topic of quality of TB care has become even more pertinent.

In this concluding article, we cover the key messages from papers in the series. We also outline some strategies for improving quality of TB care. Given the Covid-19 pandemic and its negative impact on TB services, the topic of quality of TB care has become even more pertinent.

Impact of Covid-19 pandemic on TB services
Progress in TB control was stalling, even before the Covid-19 pandemic. The 2020 Global TB report shows little change since the previous year [21]. Nearly 1.4 million people died from TB in 2019. Of the estimated 10 million people who developed TB that year, some 3 million were either not diagnosed, or were not officially reported to national authorities.
Progress towards SDG, End TB and UN High Level TB meeting targets is lagging. For example, while the target for TB preventive therapy is 30 million by 2022, only 6.3 million people have been treated during 2018 and 2019. While the target for funding TB care and prevention is $13 billion annually, only $6.5 billion were raised during 2020.
As predicted, the Covid-19 pandemic is making things worse. In September, several civil society organizations working on TB released the results of a large survey done to document the impact of the pandemic on TB care, research and funding [22]. Around the world, policy and program officers reported significant drops in TB notification. Over 70% of healthcare workers and advocates reported a decrease in the number of people coming to health facilities for TB testing. In Kenya, 50% of people with TB reported having trouble finding transport to care and in India, 36% of people with TB reported health facilities they normally visit closed.
The 2020 Global TB Report shows big reductions in TB notifications. The data show 25-30% reductions in TB notifications reported in 3 high burden countries -India, Indonesia, the Philippinesbetween January and June 2020 compared to the same 6-month period in 2019. TB services are similarly disrupted in many countries, and the disruptions extend over several months, rather than just weeks.
In India, the world's highest burden country, TB services are seriously disrupted, and the disruptions extend over several months, rather than just weeks [23]. India is dealing with a large-scale syndemic of TB and Covid-19.
A model by WHO [21] suggests that the global number of TB deaths could increase by around 0.2-0.4 million in 2020 alone, if health services are disrupted to the extent that the number of people with TB who are detected and treated falls by 25-50% over a period of 3 months.
The first pressing priority is to catch-up on all the missed patients and offer them TB treatment, in both public and private health sectors. It is also critical to ensure that everyone on TB therapy is adequately supported to complete the full duration of treatment. In this context, the key messages in the 19 articles in our series are highly relevant. Table 1 attempts to summarize the key messages in the 19 articles in the series. The articles clearly demonstrate that poor quality of TB care is a major issue in all subgroups (adults, children), in all forms of TB (childhood, latent and DR-TB), and in a variety of countries and settings [2,3,5,10,12,15]. Standardized patient (SP) studies in 4 high-burden countries showed that few patients were offered appropriate diagnostic tests but many were offered empirical therapies, including broadspectrum antibiotics and steroids [2]. Several articles described the socalled "know-do" gap in which healthcare workers can describe best practices in theory but don't necessarily implement them in practice [2,4]. Other articles highlighted the importance of high-quality health systems (as part of universal health coverage [UHC]) in improving the quality of TB care, arguing for a shift in focus from the quality of individual providers to the strength of the health system at every level of care in both public and private sectors [5,6,8,11,14,18]. The series also highlights the importance of the private health sector in many high TB burden countries, and the importance of engaging private providers to improve quality of TB care [13,20].

How can we improve quality of care?
In addition to pointing out key gaps in care quality, some of the articles outline several potential solutions ( Fig. 1 provides a high-level summary). A clear consensus is that improving the quality of TB care cannot be accomplished in a vacuumit requires UHC and approaches that target the foundational strength of robust health systems [5,6,8,11,14,18]. Quality in TB care needs to be better defined so it can be measured [5,11], and it must be centered on patients' perspectives to ensure that their needs and expectations are addressed [19]. Efforts to improve quality of TB care can be designed with lessons learned from other disciplines as a guide [6]. Promising approaches proposed in these articles included using existing tools and approaches for quality improvement [7,14] and pursuing a research agenda that investigates  reasons for losses at each stage of the TB care cascade [11]. When the series was launched in 2019, we had hoped it would result in a robust and sustained conversation about quality TB care, a topic that has heretofore been woefully neglected. At the start of 2021, we find ourselves in a crisis, where the TB epidemic has worsened because of the Covid-19 pandemic. Given the massive setback to progress in reaching any of the TB targets, it's time for the TB community to leverage Covid-19 innovations and systems (e.g. home-based and tele-health care, rapid and easy access to testing, digital adherence tools, real-time data tracking, sick pay and social benefits) to improve TB care and get back   on track [24]. In fact, there cannot be a more opportune moment for the TB community to leverage Covid-19 innovations to reimagine TB care, and make universal health coverage a reality. Ethical statement The manuscript is an editorial with no original data. Ethics approval is not applicable.