From diagnosis to treatment: Streamlining TB care pathways in the hilly terrains of Shimla district.

Background & objectives Tuberculosis (TB) remains a significant public health challenge in resource-limited settings like Shimla District, Himachal Pradesh, where delays in anti-tubercular treatment (ATT) initiation persist due to geographic and systemic barriers. This study aimed to evaluate the effectiveness of quality improvement interventions in reducing treatment delays using plan-do-study-act (PDSA) cycles. Methods The study implemented three interventions targeting different operational barriers: decentralising treatment initiation by routing diagnostic results to local TB units, enabling treatment initiation during holidays through accredited social health activists (ASHAs), and enhancing communication between molecular testing laboratories and peripheral units via multimedia groups. Data on delays (≥3 days) were collected from the Nikshay portal and analysed pre- and post-intervention. Results The interventions significantly reduced treatment delays, with the proportion of delayed cases dropping from 31 to 15 per cent after the first intervention. While the second intervention sustained a delay rate of 16 per cent, the third intervention further improved timeliness in rural hospitals, highlighting the critical role of efficient communication systems. However, resistance from healthcare providers in district hospitals limited the overall impact of the interventions. Operational challenges such as overburdened molecular laboratories and delays in updating results on the Nikshay portal were also identified. Interpretation & conclusions Quality improvement strategies, including decentralisation, holiday coverage, and enhanced communication, effectively reduced ATT initiation delays, particularly in rural settings. Addressing systemic inefficiencies and engaging stakeholders are critical for sustained improvements. These findings offer scalable solutions for TB programmes in similar resource-constrained contexts, contributing to global TB control goals.