



































TB cases detection in Tajikistan – analysis of existing obstacles


 

 

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TB case detection in Tajikistan - 

analysis of existing obstacles 

 

 

Alexei Korobitsyn1, Oktam 

Bobokhojaev2, Thomas Mohr1, 

Jamila Ismoilova1, Mavluda 

Makhmudova1, Alex Trusov1 
 

1Project HOPE; 2National TB Centre, 
Dushanbe, Tajikistan 

 

 

 

Vol. 2, No. 2 (2013) |   ISSN 2166-7403 (Online) 

DOI 10.5195/cajgh.2013.48 |   http://cajgh.pitt.edu 

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Abstract 

Background: Tajikistan National TB Control Program 

Objective: (1) To identify the main obstacles to increasing TB Detection in Tajikistan. (2) To identify interventions that improve 

TB detection. 

Methods: Review of the available original research data, health normative base, health systems performance and national 

economic data, following WHO framework for detection of TB cases, which is based on three scenarios of why incident cases of 

TB may not be notified. 

Results: Data analysis revealed that some aspects of TB case detection are more problematic than others and that there are gaps 

in the knowledge of specific obstacles to TB case detection. The phenomenon of “initial default” in Tajikistan has been 

documented; however, it needs to be studied further. The laboratory services detect infectious TB cases effectively; however, 

referrals of appropriate suspects for TB diagnosis may lag behind. The knowledge about TB in the general population has 

improved. Yet, the problem of TB related stigma persists, thus being an obstacle for effective TB detection. High economic cost 

of health services driven by under-the-table payments was identified as another barrier for access to health services.  

Conclusion: Health system strengthening should become a primary intervention to improve case detection in Tajikistan. More 

research on reasons contributing to the failure to register TB cases, as well as factors underlying stigma is needed.  

Keywords: tuberculosis, detection, health services, access 

 

TB case detection in Tajikistan - 

analysis of existing obstacles 

 

Alexei Korobitsyn1, Oktam 

Bobokhojaev2, Thomas Mohr1, Jamila 

Ismoilova1, Mavluda Makhmudova1, 

Alex Trusov1 
 

1Project HOPE; 2National TB Centre, 
Dushanbe, Tajikistan 

Research 

Tajikistan is a landlocked country in Central 

Asia, bordering China, Afghanistan, Uzbekistan and 

Kyrgyzstan, formerly part of the Soviet Union, with a 

territory of 143.1 thousands sq. km and population size 

of 6,952,223.
1 

The majority of its territory (93%) is 

mountainous. According to World Bank data, Tajikistan 

is the poorest country in former Soviet Union with a 

Gross National Income (GNI) per capita USD 800.
2
 

The country gained independence in 1991. In 

1992-1997, however, Tajikistan plunged into civil war. 

As a result of this fratricidal conflict, various sources 

estimate that between 40,000 to 100,000 people died, 

thousands were handicapped, about a million became 

refugees and internally displaced, more than 50,000 

households destroyed, and a damaged economy 

estimating at a US$7 billion.
3
 The effect of the conflict 

on health care has not been studied; however, it is 

logical to assume that the health system infrastructure 

and human resources suffered along with other parts of 

a civil society. 

Tuberculosis (TB) is among the most important 

public health problems in Tajikistan. In 2010, the TB 

notification rate amounted to 92/100,000 for all cases.
3 

World Health Organization (WHO) estimated a TB 

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mortality rate of 41/100,000 in 2010, which ranks 

Tajikistan highest in the WHO EURO region.
3
 

The WHO promoted Directly Observed 

Therapy Short (DOTS) course strategy implementation 

was started in 2 pilot districts in 2002 by Project HOPE, 

international Non-Governmental Organization (NGO), 

and the support of United States Agency for 

International Development (USAID). The massive 

scale-up of the new TB control strategy started in 2004, 

accelerated with support from the Global Fund to Fight 

AIDS, Tuberculosis and Malaria, and by the end of 

2007, the strategy was implemented in the whole 

country.  

The National TB control strategy adopted in 

2010 in Tajikistan is aligned with the Global “STOP 

TB” strategy and has among its objectives detection of 

70% of all existing TB cases in the country and the 

successful treatment of 85% of cases.
1
 

TB detection is primarily taking place in 

Primary Health Care (PHC) facilities where individuals 

are evaluated by physicians and undergo sputum smear 

microscopy if TB diagnosis is suspected. TB reference 

diagnosis is made on a regional level in tertiary health 

facilities.  

The treatment success rate (TSR) in Tajikistan 

reached WHO target level (85%) in 2006.
3 

That, 

however, was attributed to the 40 pilot districts 

implementing the DOTS strategy (approximately 2/3 of 

the country population). In 2007, rapid expansion of the 

DOTS strategy was undertaken, and 100% coverage 

was achieved within 1 year. Thereafter, there was an 

observed gradual negative trend in TSR (83% in 2007-

2008, 81% in 2009).
3
 

There were efforts undertaken to verify quality 

of the data on treatment outcomes in 2009-2010. 

Randomly selected primary documentation was verified, 

with a focus on whether it was complete and sufficient 

to support the fact of the sputum conversion. In 

approximately 90% of the cases, the existing primary 

documentation was judged sufficient to support the 

quality of the data.
5
 

The WHO estimated case detection rate (CDR) 

in Tajikistan for 2009-2010 was 44% (36-54%) for all 

cases, which was the lowest in the WHO EURO 

region.
3 

The trend of low case detection has continued 

for the last 14 years. From 1995 to 2005 (after civil war 

ended), there was minimal positive dynamics in case 

detection rate, 1-2% per year. Even though in 2005 to 

2008 there was a period of rapid DOTS strategy scale 

up, there was no substantial increase in CDR in 2009 

(all countries covered by DOTS) or 2010. According to 

the WHO global TB report in 2010, Tajikistan case 

detection was substantially lower than average case 

detection of the central Asian countries (67.2%, p < 

0.0001), former Soviet countries (75.0%, p < 0.0001), 

and European WHO region in general (87.2%, p < 

0.0001), thus demonstrating one of the lowest CDR in 

the world.
3
 

 

Objective 

This article analyzes the underlying reasons for 

the low TB case detection in Tajikistan. It attempts to 

answer the following questions: What are the main 

obstacles for improving TB case detection in Tajikistan? 

Are those obstacles only within health sector? What 

interventions can increase case detection?  

According to the WHO framework for 

assessment of TB cases detection, there are three main 

reasons why incident cases of TB may not be notified: 

(A) Cases are diagnosed but not reported. For patients in 

this category, strengthening surveillance systems, 

establishing links with the full range of heathcare 

providers for effective information exchange, and 

corrective measures for early patient default will help. 

Stronger enforcement of legislation regarding 

notification of cases (where this is mandated by law) is 

important as well. (B) Cases seek care but are not 

diagnosed. For patients in this category, better 

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diagnostic capacity is needed. This means better 

laboratory capacity as well as knowledgeable and 

experienced staff, both laboratory technicians and 

clinicians, especially in peripheral-level healthcare 

facilities. Normally, this is achieved through quality 

training, on-the-job mentoring linked to a monitoring 

system. (C) Cases do not seek care. For people in this 

category, reasons include not recognizing any 

symptoms of TB and/or no access (financial or 

geographic) to healthcare services, or seeking care 

outside of “official” health services boundaries (i.e. 

either from traditional healers or privately from known 

health professionals). The latter option may occur either 

due to above-mentioned financial/geographical 

constraints or due to stigma. To reach cases in this 

category, health systems need to be strengthened so that 

basic healthcare services are available to more people, 

and financial barriers to diagnosis (and subsequently, 

treatment) need to be mitigated or removed. The general 

population needs to be aware of TB symptoms, 

prevention, and care principles following evidence-

based approach.
6
 

In order to understand reasons underlying each 

of these scenarios, available data from related studies 

conducted in Tajikistan were analyzed. The analysis 

was supported by the data from public domains 

(government strategies and reports, international 

development data sources). 

 

Analysis of the Problem 

(A) Cases are diagnosed but not reported 

The first possible group of reasons “cases are 

diagnosed but not reported” may include two options – 

TB cases may be treated without reporting or not 

reported due to early default. There is anecdotal data in 

regard to the former option in Tajikistan; however, no 

systematic studies were undertaken. The current 

analysis will focus on the latter option - “initial default.” 

Substantial attention was given to this phenomenon 

recently worldwide. In 2008, the “International Journal 

of Tuberculosis and Lung Diseases” published three 

original articles on the initial default.
7-9

 An initial 

defaulter is a patient who was detected in a smear 

microscopy laboratory and consequently recorded in 

laboratory register as a sputum smear-positive, but was 

not registered in TB patient register and, hence, did not 

start treatment.
10

 It is recognized that phenomenon of 

initial defaulters limits both detection (registration) and 

treatment outcomes of TB cases in society.
10

 The 

referenced original studies documented frequency of 

initial defaulters from 5% (India) to 26% (South 

Africa).
8,9

 

The problem of initial defaulters as a 

contributing factor to the low case detection rate was 

studied in Tajikistan to a limited extent. As part of 

routine monitoring visits, the registration of new 

pulmonary SS+ TB cases was cross-checked in 

microscopy laboratory register (TB 04) and TB district 

register (TB 03)  in selected districts in Quarters 3 and 4 

in 2008 and Quarters 1 and 2 in 2009. During that 

period, 45 out of 254 (18%) sputum smear positive 

cases were revealed as unregistered. Of those 45.6% 

(27) were inhabitants of other districts. The reasons the 

remaining 18 unregistered cases did not start treatment 

were: 2 deaths, 1 refused to start treatment, 1 moved out 

of the country, and 1 was imprisoned. 13 cases (29%) 

did not start treatment for unidentified reasons.
11

 

The analysis of initial defaulters in Tajikistan 

revealed two important findings: firstly, that people are 

commonly referred to a different district than the one 

they reside in for a sputum microscopy test (10.6% of 

detected SS+ cases were residents of neighboring 

districts). Secondly, among newly detected SS+ cases 

who are residents of same districts, initial defaulters 

have comprised on average 7.9% (18/227), being as 

high as 25% (13/52) in the least effective DOTS center. 

The major limitation of this study is that reasons for 

initial defaults for the large portion of patients were not 

investigated further.
11

 

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(B) Cases seek care but are not diagnosed 

This scenario includes TB cases visiting health 

services but not being diagnosed. There are two 

principal reasons for that – laboratory service fails to 

detect Mycobacterium tuberculosis or primary health 

care service fails to refer appropriate suspects for TB 

laboratory test. We will analyze each of the above-

mentioned contributing factors in Tajikistan.  

To successfully detect TB cases, better 

diagnostic capacity is needed. The latter assumes 

availability of equipment, disposable supplies, qualified 

laboratory and clinical staff, and effective referral 

patterns.
3
 

Though recent advancements in TB laboratory 

technologies are promising, sputum smear microscopy 

is still the primary basis for TB diagnosis, being 

effective and efficient in detecting most 

epidemiologically dangerous TB cases (i.e. excreting 

large amounts of Mycobacterium tuberculosis). Even 

though more sensitive methods are important for 

increasing TB case finding, smear microscopy remains 

the cornerstone of TB detection, especially in less 

developed countries. For these reasons, the article will 

focus only on sputum smear microscopy. 

In March 2010, officially there were 97 

designated microscopy laboratories in Tajikistan, 

roughly 1 per 70,000/population. However in practice, 

only 92 microscopy laboratories were functioning. The 

laboratories are generally centralized at the district 

(nokhia) level; however, certain districts have more than 

one laboratory due to larger population (>100,000) 

and/or accessibility reasons, (remoteness and/or 

mountainous terrain). Each TB suspect upon presenting 

at a microscopy laboratory is recorded in TB laboratory 

register (TB 04), where test results are recorded. 

Diagnosis of TB cases by means of smear 

microscopy is a priority both for the NTP and 

international partners in TB control, attracting major 

financial resources and being a target for a technical 

support. Between 2005 and 2010, smear microscopy 

increased both in number and in quality, suggesting 

these concerted efforts are successful (Table 1). 

 

Table 1. Smear microscopy results in Tajikistan 2008-

2011. 

 

Effective referral mechanism is another factor 

contributing to quality TB diagnosis, which consists of a 

well-performing health workforce and sound 

management practices. 

A well-performing health workforce is one that 

works in ways that are responsive, fair, and efficient to 

achieve the best health outcomes possible, given 

available resources and circumstances (i.e. there are 

sufficient, competent, fairly distributed staff; they are 

responsive and productive).
12

 

Improving the performance of the health 

workforce was one of the objectives for Knowledge, 

Attitude and Practice (KAP) surveys implemented in 

2005 and 2008 jointly by the international NGO Project 

HOPE, WHO office in Tajikistan, Sino Project/Swiss 

Center for International Health with funds from Global 

Fund to fight AIDS, Tuberculosis and Malaria (GF) and 

USAID. In 2008, 185 doctors and 357 nurses working 

in primary health care have participated in the survey. 

The health providers were questioned if they have 

passed formal training in principles of the DOTS 

strategy. There was an attempt to evaluate their 

competence as well. Only 43% of doctors and 32% of 

nurses had attended DOTS courses during the last five 

years preceding the survey. Regarding the quality of 

knowledge, 72.4% of physicians, compared to only 29% 

of nurses, working in primary health care correctly 

noted that the first step in TB diagnosis is a referral for 

microscopy examination (Table 2).
13 

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Table 2.Suggested actions of PHC providers toward TB 

suspects. 

 

Quality of sputum is a critical factor 

influencing TB diagnosis. The same survey showed 

nurses have insufficient knowledge about contributing 

factors to collecting quality sputum samples (Table 3).
13 

 

Table 3.Knowledge of factors influencing the reliability 

of sputum smear microscopy results. 

 

Another critical factor for making correct TB 

diagnosis is following the TB diagnostic algorithm. 

When TB is suspected (prolonged cough, abnormalities 

on a chest X-ray) but the smear microscopy result is 

negative, the diagnostic algorithm indicates prescribing 

broad-spectrum antibiotic therapy. According to the 

study results, PHC physicians followed this algorithm 

only in 38.9% of cases.
13

 

 

(C) Cases do not seek care 

The third group of reasons for not detecting TB 

cases can be attributed to the situation when “cases are 

not seeking care.” The following reasons in this group, 

which are of utmost importance for Tajikistan: (1) 

stigma, (2) high economic cost of the medical services, 

and (3) lack or insufficient knowledge of TB symptoms 

by the general population. 

The stigma attached to tuberculosis in many 

societies has been recognized as a major global cause of 

the limitations of the World Health Organization’s 

DOTS strategy for TB control.
14

 In the 1960s, stigma 

was defined by Goffman as “an attribute that is deeply 

discrediting” and the stigmatized as “individuals who 

are negatively regarded by the broader society and are 

devalued, shunned or otherwise lessened in their life 

chances.”
15 

Jones et al. proposed that people are 

stigmatized “when they are found to possess a mark that 

makes them deviate from a prototype or norm.”
16

 

It was broadly studied and proved that, for TB 

patients, stigma has a major impact on access to health 

care. It affects healthcare seeking behavior, as people 

are hesitant or choose not to disclose their symptoms to 

family members, friends or neighbors for fear of 

possible isolation and hostility towards them.
15-17

 

In Tajikistan, stigma related to TB was studied 

in depth within KAP surveys as well. In 2005, TB 

patients (n=350) were asked if they noticed a change in 

attitude among family members toward them once the 

diagnosis of tuberculosis was revealed. About 15% of 

the patient respondents noticed deterioration in attitude 

toward them.
18 

The results of survey in 2008, as well as 

in 2005, showed that the majority of the respondents 

believe that TB patients should be isolated (2005-84%, 

2008-94.4%). More than 52% of them noted that TB 

patients should be isolated for the entire period of 

treatment; 32% - until their health improved and 15% - 

for contagious period only.
13,18

 

The manifestation of stigma is more distinct on 

a personal level. Even though the majority of 

respondents from the general population in 2008 

believed that TB can be cured (84%), at the same time 

45.3% of them indicated that they would not accept a 

former TB patient into their family.
13

 Reasons for 

refusal to accept people with TB into families were 

explained by respondents as following: fear to be 

infected with TB (48.9%), TB can be inherited (25.2%), 

and risk of re-infection (24.1%). These data correlate 

with self-reports from TB patients, when over 50% of 

respondents among TB patients of marital age, both 

men and women reported difficulties when creating a 

family and high level of TB related stigma among 

migrant workers.
13,19

 

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Illness often results in an economic burden for 

individuals as well as households, especially for socially 

disadvantaged and impoverished groups of the 

population.
20

 The negative economic effect is further 

exacerbated in a situation when social support is 

missing.
21

 In case of underfunded health services, the 

private out-of-pocket payments can become an 

important source of health system financing.
22,23 

There 

is overwhelming anecdotal data of prevalent private out-

of-pocket payments for health services in Tajikistan. 

These facts were confirmed at least by several 

systematic studies.
13,18,24-26

 

The “KAP” surveys conducted in 2005 and in 

2008 documented the problem of unofficial payments 

for health services in Tajikistan along with their 

possible detrimental effect for TB care.
13,18

 In 2008, 1/3 

of respondents representing general population stated 

that TB treatment is provided on a pay basis.
13

 Over 

68% stated that key reason of delayed care seeking is 

shortage or lack of money (in 2005, 67.5%) whereas 

only 7.3% of them mentioned lack of knowledge of TB 

symptoms as reason for delayed care-seeking (2005- 

26%).
13,18

 

The study on household costs of illness during 

different phases of TB treatment found that an illness 

episode cost averaged as high as $1,053 USD, with a 

peak in early stages of treatment ($145 per month 

before the start of treatment, $153 per month in an 

intensive, and $95 in a continuation phase, p < 

0.0005).
24

 These costs not only seriously compromise 

affordability, but also have a devastating effect on an 

household budgets in Tajikistan.
24

 

Finally, knowledge of TB symptoms by 

general population plays an important role whether 

patients are seeking care, should symptoms of TB occur. 

It has been proven in a number of countries that 

educational campaigns among population may increase 

both use of health services by general population and 

number of newly detected TB cases.
27

 

The comparison of 2008 and 2005 KAP survey 

results indicate improvement in awareness of TB 

transmission among the population in the pilot districts. 

Comparative analysis revealed that 63.7% of 

respondents in the 2005 survey mentioned cough as a 

basic TB symptom, versus 84.9% of respondents in 

2008. There is also increase in respondents’ knowledge 

of other TB symptoms. In 2005, over a quarter of 

respondents could not define any of TB symptoms 

versus just 7% in 2008. According to 2008 survey 

results, the majority of respondents (61%) believe that 

the transmission through air (2005, 25.3%) and 

commonly used items (27.3%) are the main ways for 

TB transmission. Taking into account that the latter 

(contact) mode is not epidemiologically significant, this 

rate (27.3%) indicates that further public education is 

needed. While 20% of respondents in 2005 were not 

aware of the means of TB transmission, in 2008 survey 

this decreased to 5.2%.
13, 18

 

 

Discussion 

Detection of TB cases is an essential 

component of TB control. Its objective is to identify 

infectious TB sources in society and treat them, thus 

discontinuing chain of transmission of TB infection.
28

 

While it is considered critical to prioritize efforts to treat 

earlier detected cases of tuberculosis,
29 

it is also 

important to look into detecting the highest possible 

proportion of them in order to achieve sustainable 

control of the tuberculosis epidemic. 

Tajikistan has achieved tangible progress in 

treatment of TB cases, despite having the lowest TB 

detection rates in the WHO EURO region (44% in 

2010). Therefore, TB detection needs to be 

strengthened, and new approaches applied in order to 

further improve the trend of TB case detection. 

The analysis reveals that some aspects of TB 

case detection are more problematic than others, 

whereas certain gaps in knowledge of specific obstacles 

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to TB case detection exist. Thus, the scenario “cases are 

diagnosed but not reported” is studied considerably less 

than others. The phenomenon of treatment without 

registration and reporting due to various reasons 

(stigma, deprived access to health services due to either 

distance or financial affordability, belief in traditional 

healers) was not studied. Alternatively, there have been 

attempts undertaken to study and prove the phenomenon 

of “initial default” in Tajikistan. The preliminary 

analysis has shown that majority (60%) of initial 

defaulters are residents of the districts different from 

those where they seek health care. It is not clear at this 

stage why this has happened, which may be due to 

stigma or family connections and needs to be studied. 

At the same time the system of information exchange 

between districts requires urgent improvement. 

For “cases that seek care but are not 

diagnosed,” it appeared that laboratory services detect 

infectious TB cases rather effectively, whereas referral 

of appropriate suspects for sputum smear microscopy 

possibly lags behind. The problem may be related to the 

qualification and performance of the health staff, which 

is possibly being impacted by training and monitoring 

or by the effectiveness of referral pattern of the existing 

TB suspects, integration and collaboration between TB 

and PHC services.   

The scenario “cases do not seek care,” 

appeared to be explored extensively, with two KAP 

surveys conducted in 2005 and 2008 as well as several 

other studies yielding mutually supportive results. 

Starting from 2002, concerted efforts have been applied 

for public education in regard to general information on 

TB, which produced measurable results. Yet, the 

problem of TB attached stigma persists, being one of 

obstacles for the effective TB detection in Tajikistan. 

High economic cost of health services driven 

by under-the-table payments was identified as another 

barrier for access to health care. While a simplistic way 

of regarding this phenomenon would be to call it 

“corruption” leading to punitive measures only, deeper 

assessment, supported by a number of studies, is that 

viewing informal payments as a characteristic of health 

system frailty which necessitate health system 

strengthening rather than police measures. If average 

official salary of doctors in 2011 was USD $71 (Tajik 

somony 337),
30

 when health services are severely under-

funded, under-the-table payments become a means of 

survival and are difficult to mitigate through punitive 

action.  

 

Conclusion 

Low case detection in Tajikistan is a complex 

problem with barriers to its improvement lying on 

different stages of the TB diagnostic path within health 

system domain as well as beyond. 

Based on results of this study, it may be 

plausible to suggest health system strengthening (HSS) 

activities, broadly defined elsewhere as a logical 

primary approach to increase of TB detection in 

Tajikistan.
31

 The information collected and analyzed in 

this article suggests that suboptimal qualification of 

health cadres, ineffective management and supervision 

practices, and suboptimal health funding mechanisms 

are contributing to losing detected cases as “initial 

defaulters,” ineffectively referring of TB suspects, and, 

finally, prohibiting access to health services through 

high informal payments. 

More research on unofficial treatment for TB 

patients outside of TB services, reasons contributing to 

“initial default,” especially from the perspective of a 

patient, and factors underlying TB-related stigma is 

needed.  

 

References 

1. National program for tuberculosis protection of the 

population of the Republic of Tajikistan, 2010-2015. Dushanbe. 

2010. 

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Volume 2, No.2 (2013) |  ISSN 2166-7403  (online)| DOI 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu 

 

 

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Central Asian Journal of Global Health 

Volume 2, No.2 (2013) |  ISSN 2166-7403  (online)| DOI 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu 

 

 

Table 1. Smear microscopy results in Tajikistan 2008-2011. 

 

 DM (PHC+TB 

services) 

# positive PR (%) DM (PHC) # positive PR (%) 

2008 28619 2900 10 12077 538 4 

2009 37175 3568 10 16708 712 4 

2010 40712 3896 10 19555 925 5 

2011 

(9 months) 
31705 2774 9 14648 1036 7 

Note: DM – diagnostic microscopy; PHC – primary health care services; PR – positivity rate. 

 

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KOROBITSYN 

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-No Derivative Works 3.0 United States License. 

 

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Central Asian Journal of Global Health 

Volume 2, No.2 (2013) |  ISSN 2166-7403  (online)| DOI 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu 

 

 

 

Table 2.Suggested actions of PHC providers toward TB suspects. 

 

 PHC Doctors PHC Nurses 

Referral to sputum collection spot 72.4% 28.9% 

Referral to DOTS center 11.4% 32.5% 

Referral to TB center 3.2% 30.0% 

Referral to X-ray room 13.0% 3.4% 

Do not know 0.0% 0.8% 

Other 0.0% 4.5% 

Note: PHC-primary health care services. 

 

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

This work is licensed under a Creative Commons Attribution 3.0 United States License. 

 

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of its D-Scribe Digital Publishing Program, and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 2, No.2 (2013) |  ISSN 2166-7403  (online)| DOI 10.5195/cajgh.2013.48 |http://cajgh.pitt.edu 

 

 

 

Table 3.Knowledge of factors influencing the reliability of sputum smear microscopy results. 

 

 PHC nurses, providing correct answer 

Controlled sputum collection 40.9% 

Following sputum collection techniques 65.3% 

Number of sputum samples examined 5.3% 

Adequate instructions for patients 14.0% 

Qualifications of laboratory technician 17.6% 

Other 8.8% 

Note: PHC-primary health care services. 

 

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