A mixed-method evaluation of the impact of introducing 52 digital X-ray systems in Ghanaian health facilities on tuberculosis case finding and quality of care.

Between end 2016 and early 2018, 52 digital X-ray systems were installed in public health facilities across Ghana under the ORIO program, funded by the Dutch Ministry of Foreign Affairs and the Government of Ghana. The project aimed to detect more people with TB by expanding access to digital radiology, supported by training, maintenance, and project management. This evaluation assessed the project's contribution to TB case finding, diagnostic capacity and access to TB diagnostic services between 2017 and 2022. The evaluation used a mixed-methods approach, including 21 key informants interviews from national to facility level, and 87 semi-structured interviews with TB coordinators, OPD doctors, radiographers and X-ray clients at 26 facilities. We analyzed district- and facility-level TB notification data (2014 - 2022), and numbers of X-rays and chest X-rays performed. The project was widely perceived to have improved access to TB screening and diagnosis by reducing cost and distance barriers. Challenges included a shortage of radiographers, lack of uniform screening guidelines, and poor internet connectivity. While TB notifications increased at district level after the installation of the digital x-ray machines, increases were not seen at facility level, suggesting machines served a regional diagnostic function. Interviews supported this interpretation. Considerable variation in TB notifications trends across sites was observed. Underutilization and a low proportion of chest X-rays likely played a role. Machines were more often used for non-chest imaging. The project strengthened the health system through increased access to X-ray screening and diagnostic services for TB, lung-related diseases, and other conditions. Effective and sustainable integration of digital X-ray technology requires understanding of the operational context, robust protocols, and addressing staff shortages and turnover. Reliable internet is critical for real-time monitoring and optimizing machine usage to improve TB management and expand diagnostic capabilities.