Socio-demographic characteristics of the respondents
Quantitative data were obtained from 42 TB staff who completed the structured, interviewer administered health facility assessment tool. There were more respondents in Anambra (52.4%) than Oyo state (47.6%). Most of the respondents were females (66.7%), nurses (52.4%) and the duration of service in the TB facility were less than 1 year (4.8%), 1 to 4 years (45.2%), 5 to 9 years (35.7%) and 10 years and more (14.3%). Over a third worked in public health facilities (71.4%) compared to those in privately owned health facilities (28.6%). In addition, most worked in primary (54.8%) or secondary (38.1%) healthcare facilities which were in urban (52.4%), semi-urban (2.8%) or rural (2.8%) LGAs
For the qualitative interviews in both states, there were two TB state focal persons (3.4%), 23 LGA TB Supervisors (39.7%) and 33 TB facility focal persons or designees (56.9%). Most of the interviewees were females (58.6%) and worked in public government owned facilities (72.4%). The duration of years providing TB services at the health facility were ≤5 year (50%), 6 to 10 years (43.1%) and 11 to 15 years (6.9%). Most worked in primary (44.8%) or secondary (24.1%) level facilities which were in urban (48.3%), rural (32.8%) or semi-urban LGAs (19%).
DOTS Facility Profile by States
The profile of the facilities is summarized in Table 1. Twenty-three facilities were primary (10 in Anambra State and 13 in Oyo State), sixteen secondary (10 in Anambra State and 6 in Oyo State) and three were tertiary (2 in Anambra State and 1 in Oyo State) healthcare facilities. Government-owned facilities accounted for 59.1% in Anambra state and 85% in Oyo state (see details in Table 1).
General service readiness at DOTS Facilities
Table 2 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 (95% CI: -15.29, 7.56) 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. Availability of sanitation facilities is 63.6% and 80.0% in Anambra and Oyo respectively. Findings from the in-depth interviews provide further insights on the condition of 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/RIFmachine so those are some of the challenges that we are facing” (Oyo State TB Focal Person)
In Anambra state, the gaps with the provision of basic amenities was expressed in the quote below:
“ 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 _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 most common challenge (50.0%) and (65.0%) respectively (Table 2).
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 and there is no movement of air” (Female_TB_ Facility Focal Person _Pry_ Public_Urban _ Oyo state)
With regards to basic equipment, the domain score for both states is 88.1%; 84.1% and 92.5% in Anambra and Oyo respectively (95% CI: -21.6, 4.79). Availability of weighing scale is lower in facilities in Anambra (68.2%) compared to Oyo (85.0%). The overall domain score for infection prevention in both states is 70.6%; this is slightly higher in Oyo 76.7% compared to Anambra 65.2% (95% CI: -25.3, 2.31). 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 (Details in Table 2).
General service readiness index by health facility characteristics
The general service readiness index provides a summary status of basic amenities, basic equipment, and standard precautions for infection prevention in the states. The data in Figure 1 showed that 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). This reflects the variations in the general service readiness with faith-based and private health facilities having higher values. 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) (Figure 1).
Tuberculosis specific service readiness at DOTS Facilities
Human resources, staff training and availability of guidelines
The proportion of human resources for health and TB service provision varied in both states. Over a fifth, (22.7%) of facilities in Anambra and a tenth in Oyo have only one staff. Over a third of (35.0%) of facilities in Oyo had 2 health workers while in Anambra, a fifth (22.7%) had a similar number. Almost a third, (31.8%) of facilities in Anambra had five and above personnel as against 10% in Oyo state. Six facilities had Medical Officers in Anambra as against two in Oyo (Table 3). Some of the TB facilities have inadequate staff as indicated in the quote below:
“……..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).
According to the State TB focal persons, a key factor responsible for inadequate staff at the government health facilities is the retirement of trained staff and the failure of the state and local governments to recruit adequate health workers to replace the retired staff. Another factor expressed is the inability of the State TB Control programme to influence staff distribution at all levels, especially the primary healthcare. The inadequate human resources for TB facilities is not peculiar to the public/government-owned health facilities; a similar situation was reported in the private facilities as reflected in the quote below which indicated the need for more health workers because they provide 24 hour services: The need for more staff in the private health facilities may be pressing because majority provide 24 hour services for most healthcare needs:
We also need manpower because we run 24 hours’ services (TB FP_Sec Fac_Private_Rural_1, Anambra state).
The domain score for availability of trained staff and TB guidelines is 57.1%
for both states; 57.3% in Anambra and 57% in Oyo (95%CI: -13.8, 14.4). 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 in the last two years (18.2% in Anambra and 30% in Oyo state) (see details in Table 4). The WHO SARA tool assesses staff training on various aspects of TB care in the last two years preceding the survey and this largely focuses on continuing education on TB care. According to a respondent in Anambra state, staff working at the TB clinics are healthcare professionals who had undergone modules on TB care as part of the curricula and requirement for qualification as skilled healthcare workers. However, there are gaps with continuing education and professional development on TB management. For instance, as illustrated in the quote below, some staff had not been trained on TB care though one had participated in a training on MDR TB. This reflects the training gaps as well as the unstructured and unsystematic approach to continuing education programmes on TB care in the state.
…….. all of them are trained nurses and nurse midwives [trained on TB care as part of the requirement for qualifications as skilled healthcare workers], they are all trained staff, but they have not been trained on TB management [continuing professional development and training on TB care]. That is the only problem. The other person, one of them have been trained on MDR just MDR but not on TB care. The other two have not been trained at all” (TB FP_Public_Sec_Urban_, Anambra state)
The unsystematic approach to training needs assessment and plan was also documented in Oyo state. According to a respondent, the trainings were infrequent and unpredictable as illustrated below:
“………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)
Continuing education and training gaps were also reported in Oyo state and the State TB Focal person provided more insight into the gaps in continuing education and training on TB care. Specifically, he expressed that a significant proportion of the staff have not undergone formal continuing education programme on TB care due to funding constraints. The strategy adopted is the transfer of basic skills during the onsite monitoring visits and this finding was corroborated by one of the healthcare workers as expressed below:
“the TBLS Local Government Supervisor usually organizes an [onsite] update on the latest development, for the staff working with her so everybody is informed” (Female_TB_FP_Pry_Public_Semi-urban _ Oyo state).
The domain score for diagnostics was 82.1% 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 facilities 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 DOTS 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 they will receive it 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, 3 months preceding the study, 63.6% of the facilities in Anambra state had experienced a stock out of TB drugs. However, the problem was minimal in Oyo state where only 30.0% experienced stock out of essential drugs. Furthermore, 41.7% of private facilities compared to 50% of public facilities had experienced TB drug stock out (Figure 2). According to the TB State Focal persons, TB drug stock outs occur occasionally because there is an efficient logistics management system. However sometimes, there may be delays with the importation and distribution of TB drugs which invariably results in stock outs. The quote below illustrates this point:
Well the issue (stock out) is due to the lag in the distribution of drugs…..usually, we don’t have TB drug stock out but presently, the drugs we have are inadequate and we are expecting another set…….what they (Federal Ministry of Health) told us is that there is delay in the importation and distribution of the drugs (Male_State TB Focal Person)
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.
Quotes from the in-depth interviews buttress this finding as stated below:
Now when 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=0.10) (Figure 3).