A limitation of this study pertains to the case study design with cases purposively selected and limited in number. However, at the regional level, the NTCP coordination applies the same strategy in all DHs in which a TDTC is nested. Also, at the national level, there is a standardization of the policy and guidelines of the NTCP for all 10 health regions . The two cases selected reflect the two types –public and pnfp - of DHs in Cameroon. All public DHs have a roughly similar managerial organization. Even though there will always be some differences between DHs, lessons have been learned on how to possibly improve the interface between the NTCP and DHs in Cameroon and in similar contexts. Caution is obviously due in any attempt to make broad generalisations on the basis of two cases studies conducted in a same region. Furthermore, some issues raised by this study could be further investigated using a more representative sample of districts or TDTCs for quantitative analysis.
Since 2003, in the Adamaoua region, the NTCP improved the ability of the DHs designated as TDTC to detect and treat tuberculosis cases by reinforcing the competency of staff, allocating equipment, reagents and anti-tuberculosis drugs free of charge, and putting in place a standardized HIS for tuberculosis control. The increase in the number of TDTCs has proven to be an effective strategy for improving the detection of tuberculosis cases and care for these patients .
Interventions by the NTCP do not appear to have strengthened local health systems in the manner required to achieve programme objectives and health system goals. Chee and colleagues  have made the useful distinction between ‘health system support’ and ‘health system strengthening’ activities. They classified the provision of inputs (equipment, drugs, and reagents) and trainings that are narrowly focused on specific disease control activities as ‘health system support’. Health system strengthening is ‘accomplished by more comprehensive changes to policies and regulations, organizational structures, and relationships across the health system building blocks that motivate changes in behaviour and allow more effective use of resources to improve multiple health services’. This concept is similar to what Potter and Brough  classified as sub-optimal and more effective approaches to capacity building. The NTCP interventions consist mainly of ‘health system support’, and focus on tuberculosis control support that falls short in terms of addressing structural health system constraints and building strong and sustainable local health systems .
NTCP interventions in DHs were either continuous (e.g., through the procurement of anti-tuberculosis drugs), intermittent (e.g., through supervision and training) or sporadic (e.g., through the provision of laboratory equipment). Although most sub-Saharan health services are under-staffed and under-equipped , NTCP support in Cameroon remains largely limited to facilities identified as TDTCs, most of which are located in the DHs. The NTCP continues to under-perform, with drugs and reagents frequently out-of-stock, supervision taking place irregularly, and only one annual evaluation meeting being held. The annual evaluation meeting focuses mainly on validating programme outputs produced by TDTCs rather than on analysing and addressing constraints in tuberculosis care at the district level. Hospital capacity building focuses on procuring equipment and drugs for tuberculosis control and on training only one specialised nurse and one laboratory technician for tuberculosis care. In this way, a parallel system for tuberculosis care has emerged with specific staff and a specific HIS, with monitoring and supervision of tuberculosis control activities by the NTCP managers that bypass the DHS. There is little evidence that the NTCP actually improves general health care delivery or that it strengthens the functioning of either hospital. Additionally, the DHS teams in both settings are not involved in planning, monitoring, supervising or evaluating tuberculosis control activities.
With a few exceptions—namely, a motorbike allocated to the DHA and a rehabilitated building in DHB—the effects of the NTCP are similar in both DHs, despite differences between the two hospitals in terms of technical capacity, staff number, management, revenues, and general care performance. DHs attempt to adapt to ensure the functioning of the TDTC without negatively affecting the delivery of general care and to minimize any disruptive effects. This adaptive capacity seems particularly developed in DHA that has more resources, and a decentralized management style.
NTCP strengthening district health systems is not obvious in a context where the programme itself faces difficulties in funding its proper activities and in achieving its own objectives. Strengthening district health systems, however, does not always require extra resources – it also is a matter of well-thought and well-coordinated policies and management procedures. Notwithstanding this, including the health system strengthening dimension in the NTCP portfolio may contribute to go beyond specific programmatic activities. The NTCP could then search for additional funding and expertise to reinforce the general health system – for instance via the health systems strengthening component of the Global Fund to fight HIV/AIDS, Tuberculosis, and Malaria. Indeed, strong health systems are required if disease control programmes objectives are to be reached and sustained .
Hospitals that function well with regard to their three dimensions (spatial, managerial, and technical) also have better tuberculosis control outputs. The DHA, like other faith-based hospitals, has a good reputation, is reasonably well equipped, has more-committed and specialized staff in tuberculosis control and is led by a strong management team. The DHA possessed more revenues coming from multiple sources that can be used without strict hierarchical directives, and has invested in tuberculosis control as well as in other hospital activities independently of the NTCP’s support. Even though there was a reduction in outpatients, the number of inpatients remained stable indicating that simple cases were seen at the primary health care level leading to a better use of the hospital expertise for severe cases including tuberculosis cases.
On the contrary, the DHB is less equipped and has limited amenities for patient comfort. The staff are also less engaged and are managed at the central level, with a lower capacity to generate additional resources and less flexibility in the use of these resources. At best, the DHB has detected 50% of the expected SPPT cases. This could also be explained by the lower rate of referred patients from primary health care services, in comparison with DHA. Since 2006, the increase in number of staff and the allocation of new equipment to DHB have, however, led to improved hospital utilisation and to increased detection of tuberculosis cases. But other performance indicators remained sub-optimal. These findings support the hypothesis that enhancing the functioning of DHs leads to better outputs in terms of disease control. Therefore, it is in the NTCP’s interest that district health systems, including the DHs, function better.
Our study shows that the NTCP scarcely involves the DHS and that the DHS does not properly execute its role in planning, monitoring, supervising and evaluating all district health activities, including tuberculosis control. This situation reflects what Biesma and colleagues  have called ‘missed opportunities’, or opportunities not seized that can produce positive synergies between disease control programmes and the general health system [42, 43]. These synergies are pre-requisites for attaining programme objectives and health system goals [44, 45], and achieving long-term outcomes [41, 44]. Therefore, a routine monitoring of the interface by managers of general health services and of programmes will provide avenues for optimizing the interaction between programmes and general health services by proactively searching and seizing all opportunities .
Currently, the strategy of the NTCP is a centralized strategy –with diagnosis and treatment of tuberculosis mainly in DHs-, using polyvalent staff in general health services. However, in 2011, the tuberculosis prevalence remained high −299 cases per 100000 inhabitants . Therefore, case detection and follow up should be improved to achieve the NTCP objectives. We recommend a strengthening of existing TDTCs to deliver quality tuberculosis control activities, the implication of first line health services in the detection and referral of suspect tuberculosis patients to TDTCs, and finally a gradual capacitation of the first line health services for a progressive and genuine decentralisation of diagnosis, treatment and follow up of tuberculosis cases. This decentralisation is not antinomic of keeping a strong role for DHs in tuberculosis control.