The Hidden System Behind Better TB Reporting in Nigeria

Dike Onwuamaeze

Nigeria’s tuberculosis numbers improved. But the real story may not be the one the public saw. Behind the gains was a quieter fix — one that came not from a new drug or a digital dashboard, but from solving a problem health system have lived with for years: weak coordination.

That problem is costly. It is where cases disappear between contact and notification. It is where referrals lose momentum, documentation weakens, responsibilities blur and reporting chains fail to hold. In a disease programme like TB, where performance depends on many actors moving in sequence, weak coordination is not a small administrative inconvenience. It is a direct threat to results.

For years, Nigeria’s TB response has carried that burden. Even when treatment systems improved, the harder task remained visibility — making sure cases entering the health system were properly tracked, documented, reported and followed through to the point where the programme could actually count and act on them. That was the hidden gap behind the visible progress.

And it is precisely where a new line of attention has emerged.

People close to the implementation side of the response say one reason reporting efficiency improved is that the system began relying less on generic administrative fixes and more on a field-specific coordination structure designed for public health realities. At the centre of that discussion is Rashirah Ssentamu, a Ugandan public health programme operations specialist whose coordination framework — originally developed at the Makerere University School of Public Health in Kampala and later recognised by the Uganda Allied Health Professionals Council — has drawn attention for addressing the part of health delivery many institutions still leave to improvisation.

The distinction matters.

Nigeria’s TB gains did not happen in a vacuum. They were supported by stronger diagnostics, more political focus and expanded programme pressure. But those factors alone do not explain why some systems hold their gains while others continue to leak value through missed handoffs, weak documentation and poor follow-through. In public health, execution is rarely defeated by one dramatic failure. More often, it is eroded by small operational breakdowns that accumulate until performance weakens.

For too long, that layer of failure has been treated as ordinary office administration. Institutions have responded with general workflow tools, stricter reminders, more meetings and broad management systems. Some of those interventions help. But disease-control programmes do not operate like ordinary offices. They depend on aligned field activity, deadline-sensitive reporting, compliance-grade documentation, accountable handoffs and clear visibility across multiple actors at once. A tool not built for that environment can organise work without truly controlling leakage.

That is why Ssentamu’s framework has begun to attract notice beyond East Africa. Those familiar with it describe it not as a generic management application, but as a coordination system built around the actual operating pressures of public health delivery. Known formally as the Public Health Programme Operations Toolkit, it was developed over three years at Makerere’s School of Public Health and has been since adopted School-wide. In 2024, it was presented to practitioners through the Uganda Allied Health Professionals Council before reaching implementing organisations in other countries.

It focuses on dependencies: what must happen first, what must be documented, what is due, who owns it, where delays are forming and how to intervene before a reporting failure or programme loss becomes visible too late.

In effect, it treats coordination as part of the backbone of public health performance.

That idea has become more relevant as health leaders confront a harder truth: better outcomes do not come only from more effort. They also depend on whether systems can preserve visibility and accountability from first patient contact through reporting, referral and follow-through.

In Nigeria’s TB response, that is no small issue. The system has had to manage not just disease burden, but the complexity of public facilities, private providers, laboratories, field teams, donor-linked requirements and multi-level reporting chains. Where those links weaken, the result is not only inefficiency. It is lost performance.

This is where the hidden story begins to sharpen.

According to those involved in adaptation discussions, what changed was not simply that more people worked harder. It was that a clearer coordination backbone began to hold the work together. Reporting pathways became more visible.

Responsibility became easier to trace. Delays were exposed earlier. Gaps once treated as routine friction became easier to isolate and correct.

That is the kind of shift that does not always make headlines but can materially change programme performance.

By mid-2025, the Damien Foundation — a Belgian international health organization with TB programme operations in Nigeria, the Democratic Republic of Congo, Bangladesh, and other countries — confirmed that the framework had helped tighten reporting visibility, improve follow-through across the implementation chain and reduce losses linked to weak coordination in its Nigerian operations. The Foundation described the adaptation as a practical example of how

field-specific operational design can improve public health programme performance in complex, multi-actor environments.

“What made this framework different was that it addressed the logic of public health implementation itself. It gave us a clearer way to see where reporting continuity was breaking down, where accountability needed to sit and how to reduce losses that generic management systems had not fully helped us resolve,” said Dr. Osman Eltayeb – Country Representative, Damien Foundation Nigeria

That matters far beyond one programme.

TB offers the clearest case study because it depends so heavily on continuity between diagnosis, notification, referral and ongoing monitoring. But the same underlying problem affects maternal health, immunisation, outbreak response and donor-funded public health programmes across the continent and beyond. Systems do not fail only because policy is weak or resources are inadequate. They also fail because execution is not structured strongly enough to survive complexity.

Ssentamu’s own trajectory illustrates the point. After developing the toolkit at Makerere, she has provided support to HealthBridge Uganda — a five-district public health NGO — and has since continued to provide solutions that has impacted the field. Her work moves coordination out of the shadows of administration and into the centre of public health delivery. It says the hidden architecture of implementation matters as much as the visible ambition of policy.

And in Nigeria’s case, that may explain more of the reporting gains than many have yet acknowledged.

The real lesson is simple: better TB reporting did not improve by effort alone. It improved because the system gained a stronger way to hold complex work together. In public health, that hidden backbone is often where the biggest gains are won — and where the next ones may still be waiting.