About the PPA
The patient pathway analysis (PPA) methodology was developed to better understand the alignment between patient care seeking and TB service availability. The results can inform programmatic priority setting and planning for more patient-centered availability of services.
The PPA aims to describe the steps TB patients take from the initial point of seeking care to the point of being cured. At the same time, the analysis reviews the availability of TB screening, diagnosis, and treatment at various levels of the health system. By examining the alignment of care seeking with service availability, the PPA may reveal where TB patients experience delay during care seeking or treatment initiation, access inappropriate care, or are lost to follow-up during their journey toward cure. The intent of the PPA is to help national tuberculosis programs more accurately identify some of the health systems alignment gaps that can be addressed through targeted program interventions.
The results from a PPA complement other methods of understanding programmatic gaps, including TB prevalence surveys, routine surveillance, qualitative program reviews, and special studies. Equipped with data from a PPA and other evidence, TB programs can plan TB prevention and care services in a manner that responds to patient care seeking preferences and accelerates the patient pathway to diagnosis and care.
According to the World Health Organization (WHO), more than 40% of incident tuberculosis (TB) cases in 2015—over 4 million patients—were not notified to National TB Control Programs (NTP). Whether these patients received appropriate diagnosis and treatment or not is unknown. These so-called “missing” cases fall into three groups of patients: First, some patients never accessed care because of financial, geographic, or other barriers to accessing care. Second, some patients sought care in the private (or non-state) sector and were diagnosed and treated there, but not notified to the NTP. Third, some patients were diagnosed and treated in the public sector but not notified to the NTP.
Finding these “missing” patients is essential if the goal of ending TB is to be achieved. Patient-centered care is a core principle of the WHO End TB Strategy. Where TB prevention and care services are planned from the top down, according to the available capacities of the health system, there is room to strengthen the patient-centered delivery of services by considering where services should be positioned in order to meet patients based on where they are. Essentially, instead of thinking about ‘where we can provide services,’ patient-centered care asks, ‘where should we position services?’ to most efficiently serve TB patients. The PPA was developed to help answer some of these questions.
Case Studies – Journal of Infectious Disease Supplement
Published as a supplement to the Journal of Infectious Diseases, the following case studies demonstrate how the PPA can benefit country programs at a national and sub-national level.
- Results Summary – Finding the missing TB patients: lessons learned from patient-pathway analysis in 5 countries
- Methodology Overview – Conducting Patient Pathway Analysis to inform TB programming: Methodology
- Philippines – Using patient pathway analysis to design patient-centered referral networks for diagnosis and treatment of TB: the case of the Philippines
- Kenya – Using Patient-Pathway Analysis to inform a differentiated program response to TB: the case of Kenya
- Pakistan – Delivering patient-centered care in a fragile state: using patient-pathway analysis to understand TB-related care seeking in Pakistan
- Ethiopia – Increasing access to TB services in Ethiopia: Findings from patient-pathway analysis
- Indonesia – Quality TB care in Indonesia: Using Patient-Pathway Analysis to optimize public-private collaboration
Resources for Implementation
- Patient Pathway Analysis: How-To Guide – Detailed guide for developing a PPA, designed for use by national TB programs and technical partners
- PPA Excel Template – Excel document to use as a companion to the PPA guide
- PPA Tableau Example – Example of a PPA built in Tableau; workbook is downloadable for country use
- R Script for DHS Data Analysis – Script to help summarize care seeking information from DHS raw data sets