Human resources for health at the DOTS centres
The proportion of human resources for health and TB service provision varies in both states. Over a fifth, (22.7%) of facilities in Anambra and a tenth in Oyo have only one staff. The highest proportion (35.0%) of facilities in Oyo state had 2 health workers while in Anambra, a fifth (22.7%) had a similar number. Almost a third, (31.8%) of facilities in Anambra state had five and above personnel as against 10% in Oyo state. Six facilities had Medical Officers in Anambra state as against two in Oyo state (Table 2). Some of the TB facilities have inadequate staff as indicated in the quotes below:
Table 2
Total number of health workers by cadre at the DOTS centres
Variable | Anambra n (%) N = 22 | Oyo n (%) N = 20 | Total n (%) N = 42 |
Total number of health workers | | | |
1 | 5 (22.7) | 2 (10.0) | 7 (16.7) |
2 | 5 (22.7) | 7 (35.0) | 12 (28.6) |
3 | 3 (13.6) | 6 (30.0) | 9 (21.4) |
4 | 2 (9.1) | 3 (15.0) | 5 (11.9) |
≥ 5 | 7 (31.8) | 2 (10.0) | 9 (21.5) |
Number of staff by cadre Medical Officers | 6 (27.2) | 2(10.0) | 8 (19.0) |
Community Health Officers | 2 (9.1) | 4 (13.3) | 6 (14.3) |
Public Health Nurse | 1 (4.5) | 1 (7.7) | 2 (4.8) |
Midwives | 6 (27.2) | - | 6 (14.3) |
Staff Nurses | 8 (36.3) | 5 (25.0) | 13 (40.0) |
Nurses/midwives | 4 (18.2) | 2 (10.0) | 6 (14.3) |
Senior Community Health Extension Workers | 4 (18.2) | 8 (61.5) | 15 (35.7) |
Junior Community Health Extension Workers | 3 (13.6) | 2 (15.4) | 5 (11.9) |
Environmental Officers | 1 (4.5) | - | 1 (2.4) |
Pharmacy technicians | 2 (9.1) | - | 2 (4.8) |
Medical Records Officers | 1 (4.5) | - | 1 (2.4) |
Nutrition Officers | - | | - |
Laboratory technicians | 11 (50.0) | 2 (10.0) | 13 (40.0) |
Health Assistants | 2 (9.0) | 6 (30.0) | 8 (19.0) |
“ ……..we don’t have adequate and enough staff…………. so am the one recording, am the one taking samples except the lab scientist that is helping us to diagnose on the AFB so after the laboratory scientist, the microscopy process and everything again in the sense that I will take their samples to the lab, will document the result of the lab, then if I need to place them on drugs, am the one that will do that, that is the reason why I said we don’t have enough “ (Male_TB_FP_ Pry_Public_Urban _PHC_1_Oyo State).
We also need manpower because we run 24 hours’ services (TB FP_Sec Fac_Private_Rural_1, Anambra state).
General service readiness at DOTS Facilities
Table 3 presents the results for the three domains of general service readiness, specifically basic amenities, basic equipment and standard precautions for infection prevention. The domain score for basic amenities in both states is 48.8%; 47.0% in Anambra and 50.8% in Oyo state. In Oyo, only half of the facilities (50.0%) have access to constant power supply compared to 72.7% in Anambra. On the other hand, only 59.1% of facilities in Anambra have consulting rooms with privacy compared with 85.0% in Oyo state. Availability of sanitation facilities is 63.6% and 80.0% in Anambra and Oyo States respectively.
Table 3
General service readiness at DOTS facilities by states
Variable | Anambra n (%) N = 22 | Oyo n (%) N = 20 | Total n (%) N = 42 |
Basic amenities | | | |
*Improved water source | | | |
Yes | 16 (72.7) | 14 (70.0) | 30 (71.4) |
Electricity power supply | | | |
Yes | 16 (72.7) | 10 (50.0) | 26 (61.9) |
*Improved sanitation |
Yes | 14 (63.6) | 16 (80.0) | 30 (71.4) |
Consulting room with privacy | | | |
Yes | 13 (59.1) | 17 (85.0) | 30 (71.4) |
Communication equipment | | |
Yes | 4 (18.2) | 11 (55.0) | 15 (35.7) |
Computing facilities | | | |
Yes | 1 (4.5) | 2 (10.0) | 3 (7.1) |
Domain score (mean availability of items as percent) [Mean (SE)] | 47 (4.0) | 50.8 (3.9) | 48.8 (2.8) |
Basic equipment | | | |
Weighing scale | | | |
Yes | 15 (68.2) | 17 (85.0) | 32 (76.2) |
Thermometer | | | |
Yes | 22 (100) | 20 (100) | 42 (100) |
Domain score (mean availability of items as percent) [Mean (SE)] | 84.1 (5.1) | 92.5 (4.1) | 88.1 (3.3) |
Infection Prevention | | | |
Appropriate storage of sharp waste | 14 (63.6) | 18 (90) | 32 (76.2) |
Safe disposal of sharps | 17 (77.3) | 15 (75.0) | 32 (76.2) |
Appropriate storage of infectious waste | 14 (63.6) | 18 (90) | 32 (76.2) |
Safe disposal of infectious waste | 17 (77.3) | 15 (75.0) | 32 (76.2) |
Soap and running water available | 13 (59.1) | 11 (55.0) | 24 (57.1) |
Latex gloves available | 14 (63.6) | 13 (65.0) | 27 (64.3) |
Domain score (mean availability of items as percent) [Mean (SE)] | 65.2 (5.4) | 76.7 (4.1) | 70.6 (3.5) |
Availability of structural problems in the health facility | | | |
Roof | 9 (40.9) | 8 (40.0) | 17 (40.5) |
Ceiling | 11 (50.0) | 13 (65.0) | 24 (57.1) |
Wall | 7 (31.8) | 6 (30.0) | 13 (31.0) |
Floors | 7 (31.8) | 5 (25.0) | 12 (28.6) |
Painting | 9 (40.9) | 6 (30.0) | 15 (35.7) |
Plumbing | 8 (36.4) | 6 (40.0) | 14 (33.3) |
Drainage | 4 (18.2) | 5 (25.0) | 9 (21.4) |
(*based on standards for improved water sources and sanitation promoted by UNICEF) |
With regards to basic equipment, the domain score for both states is 88.1%; 84.1% and 92.5% in Anambra and Oyo state respectively. Availability of weighing scale is lower in facilities in Anambra state (68.2%) compared to Oyo (85.0%). The domain score for infection prevention in both states is 70.6%; this is slightly higher in Oyo state 76.7% compared to Anambra 65.2%. Specifically, both states have poor availability of soap and running water, and gloves − 59.1% and 55.0% and 63.6% and 65% in Anambra and Oyo states respectively.
Findings from the in-depth interviews provide further insight on the condition of equipment and infrastructure in TB facilities. The infrastructural inadequacies in both states are highlighted in the quotes below:
"Erratic power supply is the major problem we face and we lack a generator that would have replaced the lack of direct power supply. The result that should be out within 24 hours can take days and even weeks…patients most times would have to keep calling to know when to come for their result" (Female_TB_FP_Pry_Public_Rural _Oyo state)
““the problem of electricity, you know the [Xpert MTB/RIF] is electricity driven, the erratic power supply is another problem that is affecting the optimal functioning of this Xpert MTB/RIF machine so those are some of the challenges that we are facing” (Oyo State TB Focal Person)
We have a waiting area that is not functioning because of the roof that is bad so we don’t always have space where we can gather patients to give them health education and all that is so concerning, we need help, then for the waste we don’t have any place to dispose them, then water supply we need that one also…….then ventilation here is not good enough because we share facilities with a primary health centre (for maternal and child health) and you can see that it is choked up there is no movement of air” (Female_TB_ Facility Focal Person _Pry_ Public_Urban _ Oyo state)
In Anambra state, the situation is similar as expressed in the quote below:
“Noooo. You have seen it, we don't have latrine here, we don't have chairs, and the government just give the manpower. Even this curtain was done by us to tidy this area” (TB_ FP _Pry _Public_Urban-Slum_Anambra state)
About half of the facilities in Anambra and Oyo had problems with the roof. Ceiling problems were the highest reported structural building problems in 57.0% of facilities, followed by roof (40.5%) and painting (35.7%). In Anambra and Oyo, ceiling problems accounted for the highest (50.0%) and (65.0%) respectively (Table 3).
General service readiness index by health facility characteristics
The overall general service readiness index for both states is 69.2% with Oyo state having a higher score (73.3%) than Anambra (65.4%) (p = 0.56). The general service readiness index varied by facility ownership/management; faith-based health facilities have a higher value (81.7%) than public/government owned (65.9%) (p = 0.03).Facilities in urban areas had higher general service readiness index compared to those in semi-urban or rural areas (P = 0.09). Primary health facilities had lower general service readiness index compared to secondary or tertiary healthcare facilities (P = 0.01) (Fig. 1).
Tuberculosis specific service readiness at DOTS Facilities
Table 4 presents the finding for the three domains (staff and guidelines, diagnostics, medicines and commodities) for tuberculosis specific service readiness at the DOTS facilities.
Table 4
Tuberculosis specific service readiness at DOTS facilities by states
Variables | Anambra n (%) | Oyo n (%) | Total n (%) |
Staff and Guidelines |
Guidelines for diagnosis and treatment of TB -Yes | 17 (77.3) | 18 (90) | 35 (83.3) |
Guidelines for management of HIV and TB co-infection -Yes | 17 (77.3) | 18 (90) | 35 (83.3) |
Guidelines for TB infection control -Yes | 17 (77.3) | 18 (90) | 35 (83.3) |
Staff trained for TB diagnosis and treatments -Yes | 18 (81.8) | 16 (80) | 34 (81) |
Staff trained for HIV and TB co-infection - Yes | 6 (27.3) | 0 (0) | 6 (14.3) |
Staff trained for MDR-TB - Yes | 4 (18.2) | 6 (30) | 10 (23.8) |
Staff trained for TB infection control - Yes | 17 (77.3) | 18 (90) | 35 (83.3) |
Domain score (mean availability of items as percent) [Mean(SE)] | 57.5 (5.5) | 57 (4.2) | 57.1 (3.4) |
Diagnostics |
Availability of TB microscopy - Yes | 14 (63.6) | 13 (65.0) | 27 (64.3) |
System for the diagnosis of HIV among TB clients - Yes | 22 (100) | 20 (100) | 42 (100) |
Domain score (mean availability of items as percent) [Mean(SE)] | 81.8 (5.3) | 82.5 (5.5) | 82.1(3.7) |
Medicines and commodities |
Availability of first-line TB medications | | | |
- Yes | 18 (91.8) | 18 (90) | 36 (85.7%) |
Domain score (mean availability of items as percent) [Mean(SE)] | 81.8 (8.4) | 90 (6.7) | 85.7 (5.5) |
Staff training and availability of guidelines
The domain score for availability of staff and TB guidelines is 57.1%
(SE:3.4) for both states; 57.5% (5.5) in Anambra and 57% (4.2) in Oyo states. Indicators of this domain with very low values were staff training for the management of HIV and TB co-infection (27.3% in Anambra and 0% in Oyo state) and training on MDR -TB (18.2% in Anambra and 30% in Oyo state).
The quotations below illustrate training gaps noted in Anambra:
…….. all of them are trained nurses and nurse midwives, they are all trained staff, but they have not been trained on TB management. That is the only problem. The other person, one of them have been trained in MDR just MDR but not in TB. The other two have not been trained at all” (TB FP_Public_Sec_Urban_5, Anambra state)
Similar findings were noted in Oyo where most of the interviewees reported being trained mostly during on-site step-down training by the TB Local Government Supervisor (TBLS) as expressed below:
“the TBLS Local Government Supervisor usually organizes an update on the latest development, for the staff working with her so everybody is well informed” (Female_TB_FP_Pry_Public_Semi-urban _ Oyo state).
In addition, a key finding noted was the unsystematic approach to training needs assessment and plan as documented in the quote below:
“the first training I received was at Jericho (chest clinic in Ibadan) on the diagnosis and treatment of the patient, the other training was at Kakanfo (a hotel in Ibadan) on monitoring and evaluation, main record keeping, the one at Kakanfo again was on HIV and tuberculosis. It [the training] is not frequent, its unpredictable. They will just call us whenever they feel that we needed to be updated, they will just call us maybe from the state or from the federal” (Male_TB_FP_Pry_Public_Semi-urban_ Oyo state)
In addition, the TBLS is the primary officer who benefits from the training as illustrated by the quote below:
“Refreshers training is being organized from time to time for our TBLS but actually I will say that is not sufficient because it has not gone across and there are TBLS newly posted to the DOT facility that definitely need to be trained" (State TB Focal Person).
Diagnostics
The domain score for diagnostics was 82.1% (SE: 3.7) for both states. Only two third of facilities in both states (63.6% in Anambra and 65% in Oyo states) had a TB microscopy (Table 4). All the DOTS had a system for the diagnosis of HIV among TB patients. Findings further revealed that there were functional laboratory facilities in 75% and 65% of DOT facilities in Anambra and Oyo respectively. X-ray and Xpert MTB/RIF were available and functional in 30% and 25% of DOTS centres in Anambra and 30% and 15% of facilities in Oyo respectively.
The quotes below illustrate the conditions of the laboratories in the two states.
"… we do not have a lab, we use to take our samples to the general hospital and at times it takes ten days for the result to come out and it has been giving us concern” ( Female TBLS, Rural, Oyo state ).
….but the problem is that we don’t have enough Xpert MTB/RIF material so those are the issues and even the ones that we have presently in the country they are just 4modules machine that can only handle 4samples within 2hours ….. those are some of the challenges that we are facing presently and you know generally in Nigeria we are being faced with the problem of low case finding” (State TB Focal Person)
Even when there was a laboratory facility, equipment such as Xpert MTB/RIF and microscope were either not available at all or non-functional. The following illustrates the challenges in this regard:
‘It is not good because our gene expert is not good. Only two modules are working others are not functioning. So sometimes we go to a private hospital where they have gene expert or we go to Enugu for gene expert but they are promising to repair…Another is manpower. The building is not well ventilated, the door is spoilt, and our health is in danger and we are still doing the work ( TB_FP_Secondary_ Anambra state)
Some respondents in Anambra also expressed the gaps with regards to the functionality of laboratory facilities and the turn-around time for results as stated in the quotes below:
“at times they [the general hospital where we take our sputum samples for testing] are overwhelmed with work they may have work on their hand, so at times when we go with sputum it is delayed for a week, that of last week we are yet to collect it……Yes and it may not be up to two weeks sometimes, it may be early (Male_TB_FP_Pry_Public_Rural_ Oyo state)
‘The lab results are not coming out as it supposed to. Like the one we did at the general hospital it took two days'. ( Male_FP_Private_Sec_Anambra State)
However, some private facilities have a contrary opinion as they reported that it only takes a duration of 24hrs in their facilities:
‘Sometimes it takes 24hours because if someone brings sputum this morning, you can run it and leave it at tomorrow morning’ (Male_FP_Private_Sec_Anambra State).
‘That same day. They will not wait to get it. The moment they bring the sample they will surely get it that same day’ (Female_FP_Private_Sec_Anambra State)
Medicines and commodities
The domain score for medicines and commodities was 85.7% for both states (Table 4). Ninety percent of facilities in both states (91.8% in Anambra and 90% in Oyo) had first-line TB medications at the time of the assessment. However, findings further revealed that, in Anambra state, 63.6% of the facilities had experienced a stock out of TB drugs in the 3 months preceding the study. However, the problem was minimal in Oyo state where only 30.0% experienced stock out of essential drugs. In addition, facilities have devised means of addressing the stock out such as borrowing drugs from other facilities which is returned when they receive their re-supply of drugs (Fig. 2).
Quotes from the in-depth interviews buttress this finding as stated below:
Now the drugs are not enough, the patients may be seventy-three and we may be given drugs for forty five. [So] we give the drugs of a patient to another patient till we are supplied, we order for drugs from the state and return the drug of the patient back…We manage by taking the drug of a patient and administering it out to another patient but before two weeks they supply us another drug……(Male_TB_FP_Pry_Public_Urban _Oyo state)
……in fact, if there is [delay] in bringing our drug sometimes, we normally borrow from other facilities to return immediately our drug is brought (Female_TB_FP_Pry_Public_Rural _ Oyo state)
Tuberculosis-specific service readiness index by health facility characteristics
The overall tuberculosis-specific service readiness index for the states is 75%; this is higher in Oyo state (P = 0.14) tertiary hospitals (0.34), health facilities owned by faith-based institutions (P = 0.07) and those located in semi-urban local government areas (P = 0.10)) (Fig. 3).