Strategies to reach universal access to WRDs.

Although WHO recommended rapid molecular diagnostic tools for TB over a decade ago, only about one-third of diagnostic sites in high burden countries have access to them. We conducted a mixed-methods study to understand the barriers and facilitators to reaching universal access to WHO-recommended rapid molecular diagnostics (WRDs) in a selection of African countries. Data for 24 African countries were sourced from the WHO Global TB database to evaluate the proportion of notified people with TB tested with a WRD between 2018 and 2023, and to assess access to WRDs as defined in the WHO Diagnostic Standard. Additionally, TB program staff from six countries were surveyed to identify key factors influencing the implementation of WRD-based diagnostic algorithms. Across the 24 countries, 58% of people with TB were tested with a WRD in 2023. Only in 7 countries was this proportion above 80%, with 8 countries reporting below the global average of 48%. This proportion increased by just 20 percentage points between 2018 and 2023 and remained below 25% in five Central African countries. Predominant health system barriers included supply chain disruptions, inadequate funding, staffing shortages and weak sample transportation systems. Facilitators included policy and strategic planning, expansion and optimisation of molecular diagnostic capacity, and integrated sample transport networks. Only 7 of the 24 African countries analysed are on track to meet the target for universal access to WRDs by 2027. Persisting health system barriers pose a threat to diagnostic networks and limit the effective use of WRDs. Strategic planning to address these barriers is needed to optimise the use of WRDs and maximise their impact on the TB care cascade.