In 2014, after the full endorsement of its member states through a World Health Assembly resolution, the World Health Organization (WHO) began promoting the new End TB Strategy as the global approach to eliminating TB.3 This strategy outlines three major pillars: the provision of high-quality, patient-centered prevention and care (Pillar 1); increased political will, and sustained resources for bold action (Pillar 2); and research and innovation (Pillar 3).4 Implementation of these pillars is meant to help achieve three targets by the year 2035: 1) reduce the number of new TB cases by 90% and 2) the number of TB-attributable deaths by 95%, both as compared to 2015; and 3) have no TB-affected families incurring catastrophic costs due to TB.4
To evaluate national progress toward achieving these targets, systematic program performance monitoring is recommended as part of the End TB strategy and has been widely adopted internationally.5–9 Canada is a signatory to the End TB Strategy and thus has an obligation to implement this recommendation. The purpose of such evaluations is to distinguish programs that promote health and prevent disease from those that do not.10 In turn, monitoring generates information that can be used to judge the quality and value of public health programs, like TB services.11 An appropriately designed program performance monitoring framework should document progress toward goals, identify areas for improvement and demonstrate the impact of resource investments.12
Although the importance of TB program performance monitoring in Canada has been discussed for more than 20 years, notably by Health Canada, the pan-Canadian Public Health Network and Inuit Tapiriit Kanatami, a national framework does not yet exist.13–17 In the same period, a substantial reduction in cases has not been achieved, with the overall annual incidence of TB in Canada remaining flat for 16 years, as in Figure 1 (see Chapter 1: Epidemiology of Tuberculosis in Canada).
Meanwhile, performance indicators have been adopted in other settings to assess regional and national TB prevention and care services. For example, 1 study from the United States showed marked improvements in outcomes within local health regions that actively monitored and evaluated performance relative to those that passively collected data.18 In England, where a national standard of performance indicators exists, research has contributed to recommendations for new indicators to improve the overall quality and value of TB services within the context of elimination.19 In sum, program performance monitoring has been successful elsewhere, and this chapter provides recommendations for use by TB programs in Canada.
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