Background: The directly-observed treatment strategy (DOTS) short-course approach has been adopted as an effective strategy for the management of tuberculosis (TB) and is reported to have significantly improved TB disease detection, treatment and control. In Nigeria, however, neither the set target for TB detection rate nor the cure rate has been achieved nationwide. This is due to several challenges at various levels of the health system (i.e. policy, health service delivery, community and individual levels). To unpack the research question and to also establish the relationship of the factors at the different levels within the health system, the problem was critically analysed. The process involved a brainstorming session on the different factors contributing to the core problem, descriptions of the cause-effect relationships between the different factors and grouping them under the relevant thematic areas (see diagram). The process also actively involved relevant stakeholders. A previous study by Bello et al, examined the challenges of the DOTS in the treatment of TB patients with the view to determining the obstacles to effective implementation. Associated patient-level factors included a lack of knowledge about DOT, poor adherence to medicines, co-infection with HIV, poverty and the sex of the patient. Poor counselling by the health personnel and medicines stock-outs as well as side-effects of medicines were identified at the health facility level. These observations were encountered despite the existence of national policies intended to improve the uptake of the DOTS programme.

Lessons: A comprehensive analysis of the problem identified specific bottlenecks and their mutual relationships at the various levels of the health system. This was helpful in the development of research tools, as well as recommendations for targeted interventions.