Improving early detection of TB treatment defaulters among unsupervised patients through their adherence to scheduled dates of TB drug collection at CBTO, TB treatment Centre in Lusaka Zambia | USAID Health Care Improvement Portal
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Improving early detection of TB treatment defaulters among unsupervised patients through their adherence to scheduled dates of TB drug collection at CBTO, TB treatment Centre in Lusaka Zambia

Improvement Report
Racheal Kaluta Mwape, Margaret Makukula, Evelyn Mwansa, Barbara Kashiwa

Topics: Adherence to treatment

Region and Country: Africa, Sub Saharan, Zambia

Organization: Community Based TB/HIV organisation - CBTO
The Report

Background: Community Based TB/HIV Organization (CBTO) is a non governmental organization involved in care, treatment, prevention and support activities for people infected and affected by TB and HIV. The organization is situated in a low income and densely populated community called Kamanga Compound in Lusaka, the Capital City of Zambia. In its pursuit to provide holistic and integrated care and support services to TB and HIV patients, it provides a wide range of integrated services including TB contact and defaulter tracing, treatment supervision, VCT, counseling, nutritional support, reproductive health, maternal and child health, referrals to the diagnostic centre and monitoring of notified patients. It serves as a lower referral and monitoring point for TB and HIV patients in the community it serves. Kamanga Compound, the organization’s geographic focus area, has a population estimated at 63,000 people. Presently, the organization has 138 TB patients in its care. Of these, 88 patients have regular treatment supervision (monitoring) visits from trained treatment adherence supporters from CBTO whereas 50 patients  are not visited by treatment adherence supporters because they are either working or live far from the treatment centre.

Issues: Before 2009, the organization was experiencing high TB treatment defaulter rates (35%, 2007) and high levels of patients not collecting their TB drugs on the due dates (48% intensive phase and 38% continuation phase, 2007). This problem was mostly among patients who were not being monitored from their homes by treatment adherence supporters.

There were major challenges in the early detection of patients who had missed treatment doses because the organization did not have an effective system in place to capture this information on time.

The system that was being used depended on staff checking a patient drug collection book which indicated who had collected and not collected their drugs. However, in most cases this book was only checked when someone was collecting drugs and as a result days or even weeks would have already passed before it was discovered that a particular patient had not collected their drugs and therefore had missed several treatment doses. This system was highly ineffective and inefficient.

  • 4 boxes – one for each week – labeled Week 1, Week 2 etc.

  • TB treatment cards for each patient in the intensive phase

Required (monthly drug collections – continuation phase):

  • 2 boxes – one for each month – labeled Month 1 and Month 2
  • TB treatment cards for each patient in the continuation phase
Treatment Stage Method

Intensive Phase – weekly drug collections

At the beginning of month, small cards with drug collection appointment dates for week 1 are stapled to each patient card and placed in Box 1 which is labeled Week 1

During the week, as soon as a patient collects their drugs, their card is shifted to Box 2 which is labeled Week 2

At the end of the week, all the cards remaining in Box 1 are those of patients that did not show up to collect their drugs

This cycle is repeated in week 2, week 3 and so on until patients graduate from the intensive phase into the continuation phase when drug collections are on a monthly basis


Continuation Phase – monthly drug collections

The same method described above is applied except that instead of on a weekly basis, it is done monthly

Patient cards that are still in Box 1 at the end of the month did not collect their drugs and are followed up

 Appointment dates are also written on both the card and the medicine pack so that each time the patient is taking their medicine they are reminded about their next appointment date for drug collection by seeing the appointment date stapled on the medicine pack or written on the blister pack.


The introduction of this system had an immediate impact and a drastic improvement in patients collecting drugs on time and a drop in the defaulter rate was noticed. From 2009 (when the system was introduced) to date, defaulter rates have significantly dropped and patients collect their drugs on time.

The following pie charts are a comparison of treatment outcomes for 2007 (before the intervention) and 2009 (when the intervention was introduced):

It can clearly be seen from these outcomes that the new system has significantly improved TB treatment outcomes with the defaulter rate dropping from 35% in 2007 to just 4% in 2009 when the system was introduced. Patients discharged rose from 42% in 2007 to 71% in 2009.

The number of patients not collecting drugs on time also significantly dropped from 48% (intensive phase) and 38% (continuation phase) in 2007 to 2% and 11% respectively in 2009



Remarkable improvements in service delivery can be achieved by implementing very simple and inexpensive systems. All that is required is to carefully identify the causes of the poor service delivery and start thinking of small ways to improve. Large investments are not always required to make significant improvements in service delivery. CBTO has made very significant improvements in TB treatment outcomes by simply changing the way it does things and with minimal expense. The organization highly recommends this simple system for all organizations experiencing similar problems it experienced before implementing this system