Background. Optimally performing tuberculosis (TB) programs are characterized by treatment success rate (TSR) of at least 90%. In rural eastern Uganda, and elsewhere in sub Saharan Africa, TSR varies considerably across district TB programs and the reasons for the differences are unclear. This study explored factors associated with the low and high TSR across four districts in rural eastern Uganda. Methods. We interviewed District TB and Leprosy Supervisors, Laboratory focal persons, and health

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... facility TB focal persons from four districts in Eastern Uganda as key informants. Interviews were audio recorded, transcribed verbatim, and imported into ATLAs.ti where thematic content analysis was performed and results were summarized into themes. Results . The emerging themes were categorized as either facilitators of or barriers to treatment success. The emerging facilitators prevailing in the districts with high rates of treatment success were using data to make decisions and design interventions, continuous quality improvement, capacity building, and prioritization of better management of people with TB. The barriers common in districts with low rates of treatment success included lack of motivated and dedicated TB focal persons, scarce or no funding for implementing TB activities , and a poor implementation of community-based directly observed therapy short course. Conclusion. This study shows that several factors are associated with the differing rates of treatment success in rural eastern Uganda. These factors should be the focus for TB control programs in Uganda and similar settings in order to improve rates of treatment success. Background 3 The overall goal of a tuberculosis (TB) program is to ensure people with TB who are enrolled in the program complete treatment and become cured, endpoints collectively referred to as treatment success. Directly observed therapy short course (DOTS) is a global strategy for effective control of TB and its wider application has resulted into better treatment outcomes in several countries.(1) For instance, countries which have implemented all the five components of DOTS namely sustained political or government commitment, including political will at all levels, and establishment of a centralized and prioritized system of TB monitoring, recording and training; access to quality-assured sputum microscopy; standardized short-course chemotherapy for all cases of TB under proper case management conditions, including direct observation of treatment by a healthcare worker or community health worker for at least the first two months; uninterrupted or supply of quality-assured drugs; and standardized recording and reporting system that allows assessment of treatment have reported high rates of cure and treatment completion. (2) In particular, the observation of people with TB as they take medication in real time by a treatment supporter or a healthcare provider ensures good adherence to and completion of treatment. (3) Although DOTS has been adopted and implemented widely, the achievement of the WHO desired treatment success rate (TSR) of at least 90% remains a challenge for most TB programs globally. Recent statistics suggest that the global TSR for newly diagnosed bacteriologically confirmed pulmonary TB (BC-PTB) has declined from 86% in 2014 to 83% in 2017.(4) This decline presents an unprecedented concern for TB programs because of exacerbations in TB morbidity and mortality.(5) In addition, there is significant variation in TSR across sub Saharan Africa, both between and within countries. The between country variation is seen from TSR of 83.4% in recommended.(11) Study setting This study was conducted in four predominantly rural districts in eastern Uganda, namely Soroti, Kumi, Ngora, and Serere. Soroti and Kumi districts have recently reported low TSR of 70% and 66.7%,(12) while Ngora and Serere districts have high TSR of 90.9% and 95.3%,(12) respectively. The districts were purposively selected to provide a framework for comparison of a well versus poorly performing district TB program. The variation in performance for these TB programs provides a basis and natural setting for our study. Altogether, the population in the four districts, located about 300km from Kampala Capital City, is close to one million people. We enrolled participants from TB units with the highest patient loads in the selected districts. The estimated number of new people with TB in the study districts were 191 in Serere, 340 in Soroti, 313 in Kumi, and 121 in Ngora for the period