The rate of PBS examination service in our study area was 11.6%. A significant proportion of eligible patients were not provided with PBS examination service that might have improved the clinical decision on their underlying problem. The rate of service provision is very low considering the higher number of eligible patients in the area. This finding is lower than the rate from similar studies done in the USA (27%) [28], Thailand (24.22%) [12], and Malawi (26.9%) [9]. The observed variation might have come due to the larger sample size, the socio-economic difference of our study site from these countries. While striving for universal access to health, the provision of this essential hematological test has received little attention. This reflects for the substantial gap to meet this goal in the absence of strong and sustainable laboratory service. Neglecting PBS examination renders to miss the potential added clinical value critical in the management of the patient [9, 16]. Most importantly, as depicted by Tadeu et al., lack of a laboratory service poses an extra burden by an increased probability of costly referrals, delays, and even deaths [24].
The hospital’s size, position in the healthcare hierarchy, and involvement in the quality management system affect the quantity and quality of service it provides. Likewise, the higher rate of PBS examination service provision was seen among hospitals those engaged in the SLMTA/SLIPTA project and those with a larger number of clinical staff compared to their respective counterparts. A similar pattern has been witnessed by the report from the USA [28], Senegal [29], and Addis Ababa [30], where the rate of manual blood smear scan rate elevated with an increased number of hospital beds and strengthened LQMS.
More than 20% of the patients, who visited Hematology EQA participating hospitals, have got the PBS service, compared to 5% service provision among non-participating hospitals. A similar finding was reported from India, where an external Hematology proficiency testing program has improved the quality of service provision [22]. This might be due to a lack of commitment among staff and the management together with poor supportive supervision. The majority of the interviewee reported inadequate supportive supervision. The overall management system of the hospital affects the coverage and quality of laboratory services in the hospital. This was witnessed in the study conducted by Mesfin et al, in which poor human resource management, ineffective communication system, and lack of well-established quality management system hindered the quality of laboratory services [21].
Experience and training of staff strengthen the laboratory service in the facility. Our study showed a higher proportion of the service being provided among laboratory staff those attained in-service training. Our finding is in line with the findings of studies done in different parts of Africa [15, 30]. Besides, evidence from a systematic review on studies in the USA indicated the positive influence of physicians’ experience, knowledge, and financial incentives on laboratory test utilization. In the era of strengthening evidence-based medicine the healthcare workers characteristics were affecting the pattern of laboratory service provision [23]. It is imperative to consider these variables for improving the rate of laboratory test ordering. Similarly, the interviewed medical directors in the current study stressed the vital role of training to improve service provision.
Training improves the availability and quality of healthcare. It enhances the competency and attitude of the professionals. A computer-assisted tutor on PBS in the USA helped students interpret the findings as indicated by a raised mean score of the exam from 61% in the pre-test to 91% in the post-test among students [31]. The majority of clinicians in the current study reflected a positive attitude towards PBS examination service. Even if they were convinced of its clinical significance and efficiency, they demanded training to further deepen their attitude. Lack of training on PBS service for clinicians was indicated as the challenge for sustainably providing the service. Our finding is in agreement with a study among final year medical students at Oxford University in 2010, where lack of training on Hematology shrank their attitude towards the test; which in turn reduced the service provision [23, 32]. According to the result of the study among many hospitals in the USA, clinicians gained additional information from manual PBS scan; hence, enhanced positive attitude for the service [12, 33].
Uninterrupted provision of PBS examination service demands competent laboratory personnel. In the mirror of such staff-related challenges, Hematology training provided for the healthcare workers in Tanzania improved the quality and quantity of staff [30, 34]. Likewise, the majority of the interviewed laboratory heads were not confident in their staff competency to provide quality assured PBS examination service. The concordant result was reported from Malawi, where reduced staff confidence and enthusiasm were suggested as the most important barriers to routinely provide PBS examination service in Malawi [9].
The continual availability of good quality reagents is pivotal to sustainably provide the PBS service. Lack of these resources was identified as the main challenges for PBS service in our study area. Likewise, poor provision of laboratory resources limited the quality of laboratory services in the health facilities found in Addis Ababa, Ethiopia [3, 21].
The rate of PBS examination service provision was slightly higher among patients with awareness on hematological disorder (12.2%), and those with monthly income (17.3%) compared to their respective counterparts. This could be emanated from the notion better awareness on health matter and affordability of the service strengthens the health seeking behavior and service utilization. Comparable findings were reported by Handiso et al. from Ethiopia and Sarr et al. from Senegal [29, 35].
Generally, a low rate of PBS examination service provision was observed in the study area. Lack of training, shortage of laboratory supplies, and inadequate supportive supervision were identified as barriers to the provision of PBS examination service in the study area.
Strength of the Study
To the best of our search for similar pieces of literature, this topic is less studied in our country. Besides, we have supported our quantitative findings with qualitative data.
Limitations of the Study
The scarcity of similar studies limited us to sufficiently discuss our findings. Lack of incorporation of focus group discussion in the qualitative data. Moreover, we have used the international guideline to determine the morphological abnormality of blood cells due to a lack of national guidelines.