Open Access Research article

Health system delay in pulmonary tuberculosis treatment in a country with an intermediate burden of tuberculosis: a cross-sectional study

Anamarija Jurcev-Savicevic1, Rosanda Mulic2, Karlo Kozul3, Bozica Ban4, Jasna Valic5, Ljiljana Bacun-Ivcek4, Ivan Gudelj6, Gordana Popijac-Cesar7, Snjezana Marinovic-Dunatov8* and Aleksandar Simunovic9

Author Affiliations

1 Teaching Public Health Institute of Split and Dalmatia County and School of Medicine, University of Split, Vukovarska 46, 21 000 Split, Croatia

2 School of Medicine, University of Split, Soltanska 2, 21000 Split, Croatia

3 Public Health Institute of Osječko-Baranjska County, F. Krežme 1, 31000 Osijek, Croatia

4 Public Health Institute “Dr Andrija Štampar”, Mirogojska cesta 16, 10000 Zagreb, Croatia

5 Public Health Institute of Istarska County, Nazorova 23, 52100 Pula, Croatia

6 Department of pulmonary diseases, Split University Hospital, Spinčićeva 1, 21000 Split, Croatia

7 Public Health Institute of Krapinsko-Zagorska County, Ivana Gorana Kovačića 1, 49250 Zlatar, Croatia

8 Public Health Institute of Zadarska County, Kolovare 2, 23000, Zadar, Croatia

9 Croatian National Institute of Public Health, Rockefellerova 7, 10000 Zagreb, Croatia

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BMC Public Health 2013, 13:250  doi:10.1186/1471-2458-13-250

Published: 21 March 2013



Delayed diagnosis and treatment of tuberculosis increase both the severity of the disease and the duration of infectivity. A number of studies have addressed the issue of health system delays in the treatment of tuberculosis, but mostly in countries with a high or low incidence of the disease. Our understanding of delay is quite limited in settings with an intermediate burden of tuberculosis. We explore the duration and factors associated with delays in the Croatian health system which has free health care and a sufficient network of health services providing tuberculosis diagnosis and care.


A total of 241 consecutive adults with culture-confirmed pulmonary tuberculosis were interviewed in seven randomly selected Croatian counties and their medical records were evaluated. A health system delay was defined as the number of days from the first consultation with a physician to the initiation of anti-tuberculosis treatment. A long delay was defined as a period exceeding the median delay, while an extreme delay was considered to be above the 75th percentile delay.


The median health system delay was 15 days while the 75th percentile was 42 days (the 5th and 95th percentile being 1 and 105 days respectively). Almost 30% of tuberculosis patients remained undiagnosed for more than 30 days after the initial health care visit. Female patients (p = 0.005), patients with a negative sputum smear (p = 0.002) and patients having symptoms other than the usual ones (0.027) were found to be in significant correlation with a long delay. In a multivariate model, a long delay remained associated with the same variables (p = 0.008, p = 0.003, and p = 0.037, respectively).

A significant association was demonstrated between both the female gender (p = 0.042) and a negative sputum smear (p < 0.001) and extreme delay, while only a negative sputum smear (p < 0.001) remained significant in the multivariate analysis.


Our findings suggest that some groups of tuberculosis patients experienced a health system delay. In such a setting where tuberculosis incidence is decreasing, which leads to a lack of physician experience and expertise, training in tuberculosis is required. Such measure may be useful in reducing the number of missed opportunities for tuberculosis diagnosis.

Tuberculosis; Croatia; Delay; Health system