Strengthening the response to drug-resistant TB in Pakistan: a practice theory-informed approach

Background: While Pakistan's Programmatic Management of Drug-Resistant Tuberculosis (PMDT) programme, launched in 2010, initially yielded significant gains in treatment outcomes, performance has since plateaued, and in some cases, regressed. Objective: To critically investigate why the PMDT programme, well-structured and generously resourced as it is, could not improve upon or sustain this early success and to illustrate the use of practice theory as a framework to analyse functioning of health systems. Method: A practice theory-informed ethnographic study was conducted at three PMDT clinics. The analysis drew on 9 months of participant observation and in-depth interviews with 13 healthcare providers and four managers. Results: The PMDT model primarily focused on materialities such as infrastructure, drugs and numbers of people tested, and little on developing competencies of the PMDT staff to provide responsive care. This emphasis on materialities, and the linked focus of accountability processes, led the PMDT staff to create meanings that translated into prioritisation of certain easy-to-measure healthcare practices at the expense of more difficult-to-measure practices related to responsiveness that are arguably also important for successful patient outcomes. Conclusion: A narrow focus on measurable inputs, originating from priorities set at global and national levels, influence frontline care practices with negative consequences for quality of care and patient outcomes. Greater emphasis on improving routine process of care can enhance the effectiveness of the PMDT model of care. Practice theory provides a robust analytical framework to critically interrogate health systems and healthcare provision.