ASSET NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa: Promoting Person-centred TB Care


Healthcare across sub-Saharan Africa (SSA) reaches too few of those in need (treatment gap) and does not achieve the best possible results (outcome gap). Resources are limited, so non-specialists provide most treatments. In South Africa nurses lead 90% of primary healthcare (PHC) consults, in Sierra Leone non-specialists perform 52% of surgical procedures, and Zimbabwe and Ethiopia have less than 1 psychiatrist/million. In this context, improving healthcare is challenging, but essential to progress.

Project Aim: King’s College London’s Global Health Research Unit (ASSET) aims to improve delivery and outcomes of continuing care (CC), as distinct from acute curative interventions. CC models apply to management of common chronic disease and illness episodes in PHC; hypertension, diabetes, lung disease, HIV, TB and depression contribute a large and increasing burden in SSA PHC, and often co-occur. CC is also relevant to maternal (from antenatal care and delivery to postnatal care) and surgical care (from help-seeking, referral, admission, & surgery to post-operative care). High quality CC follows evidence-based care pathways; is integrated and coordinated; and holistic, person-centred and respectful. Health system strengthening interventions (HSSI) with continuous quality improvement (QI) are needed to mould SSA services to be fit for this purpose and sustainable. Attempts to introduce guidelines or new services without addressing system barriers, and preparedness, usually fail.

Project Objectives: ASSET will work across 4 SSA countries (Ethiopia, South Africa, Sierra Leone, Zimbabwe) and 3 healthcare platforms (integrated PHC for mental and physical conditions, maternal, and surgical care), to test the practicability and effectiveness of HSSI to build capacity across platforms to deliver high quality guideline-based continuing care.

HSSI will be adapted to local contexts, piloted and refined, and then applied as a package of measures to improve care delivery. The key test will then be whether, when scaled up and evaluated at district-level, there is significant improvement in the quality of care processes, AND health outcomes. Key outcomes include; for PHC – detection, treatment and control of priority conditions; for maternal care – a composite of maternal deaths, near misses and birth complications; and for surgical care – surgical volume, deaths and complication rates.


Working group has been formally convened and the initial meeting was held in October 2017 in London. Activities to be undertaken over the next 6 months have been identified as follows:

  • Research Plan for the Working Group
  • Systematic Review-Effectiveness of different HSSI on processes and outcomes of care
  • Systematic Review-Organizational Readiness and Workforce Preparedness for Change
  • Situational Analysis – Organizational Readiness for Change
  • Adaptation of PACK and Clinical Communication Skills for Ethiopia (This is in progress and almost complete.

For WP4 (Person-Centred TB Care):

  • Meetings have been held with the Department of Health, with buy-in obtained from the provincial and district levels
  • Situation analysis fieldwork is planned to commence in January 2019
  • Situation analysis has been completed, feedback has been provided
  • Theory of Change workshops have been held in Newcastle and Cape Town
  • Working group has been established in Amajuba with DoH
  • Intervention development underway