The study was assessed based on Donabedian input-process-output service quality assessment model. The study health facilities were health centers (Mekelle , Semien , Kasech , Quiha , Adishmdihun , Aynalem, Serewat , Adiha, and Lachi ) and hospitals ( Mekelle , Quiha, and Ayder ) which has been providing Option B+PMTCT under MNCH continuum of care.
The study showed that the overall level of service quality of Option B+PMTCT was rendered as good in one out of six(16.7%) of studied health facilities. Specifically, input service quality was judged as good in 33.3% of health facilities but only 25% of them realized good process and output service quality respectively (Figure 2).
Regarding input service quality, the study revealed that majority of the health facilities were equipped with clinical care supplies and drugs for Option B+PMTCT service provision. Long life ARV regimen (TDF+3TC +EFV), and other basic obstetric care supplies for Option B+ were not reported as stock out for the past one year. However; critical input related items for Option B+ service provision were missed in considerable no of studied health facilities. Only, half of the health facilities kept on hand the necessary trained service providers, drugs for opportunistic infections, and DBS test kits necessary for the desired input service quality (Table 1).
Factors attributed to good input service quality
Regular multi-disciplinary team meeting (MDT): during an in-depth interview, majority of health service providers recognized that weekly meeting with member of MDT enabled them to identify availability related factors on time;
“…... we conduct weekly meeting with member of the MDT team and we have been raised a number of issues related to input related service demand, identify gaps, and we tried to prepare an action plan to resolve input related constraints on time ” (PMTCT client).
Factors attributed to bad input service quality
Trained staff shortage: Consistent with quantitative findings, most health workers expressed their opinion on limited trained human workforce as a barrier for input related factor due to staff turnover. On the other hand, trained staffs were preferred to serve health care services other than MNCH;
“……Imagine only two health care providers trained on Option B+ has been providing service in MNCH unit of this facility but we are serving more than an average of 80 clients per day. Having this reality, how can we provide quality service counseling? Therefore, without allocating appropriate number of trained health care providers, only integrating the service to MNCH unit may not be successful” (PMTCT service provider)
Supply chain issues for Option B+: supply chain issues reported as a challenge to rollout Option B+ successfully. Majority of study participants explained that lack of drugs for opportunistic infection was reported as a barrier for availability related factor, this was due to poor management of integrated pharmaceutical logistic system at facility level which resulted weak inventory of stock balance at the right time;
“……Some drug list used for opportunistic infection such as co-trimoxazole prophylactic therapy was reported as stock out of more than six months in the past year and stock out of drugs in PFSA and lack of transportation was a reason given for us when requested ”(PMTCT service provider).
Table 1: Health facilities not fulfilling 100% of input service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12].
Input quality items
|
No of facilities
|
Percent
|
Human resource and infrastructure
|
|
Well ventilated waiting room
|
8
|
66.7
|
Well ventilated counseling room
|
8
|
66.7
|
Cleanness of counseling rooms
|
6
|
50
|
Trained service providers on OB+
|
6
|
50
|
Medical supplies
|
|
|
Cotrimoxazole prophylaxis
|
8
|
66.7
|
DBS sample collection kit
|
7
|
58.3
|
Job aid IEC materials
|
|
|
PMTCT broachers
|
7
|
58.3
|
PMTCT leaflets
|
5
|
41.7
|
Technical guide line
|
7
|
58.3
|
PMTCT cure card
|
8
|
66.7
|
Patient forms and registers
|
|
|
Referral slips
|
8
|
66.7
|
Referral linkage slips
|
8
|
66.7
|
Appointment cards
|
8
|
66.7
|
With regards to process quality, some prominent key interventions had been missed during service consultation. Option B+ ARV drug adherence counseling and partner notification were offered in 58.3% of the health facilities. Some of the common limitations to the quality of maternity services include that women were greeted on arrival in 58.3% of the health facilities. Prolonged waiting time was also an issue observed during service consultation. It had been noted that health service providers in majority of health facilities were observed not adhered to service standards while providing the service (Table 2).
Factors attributed to good process service quality
Option B+ service integration to MNCH unit: Task shifting to scale up Option B+ by integrating the delivery of Option B+ ART initiation as one service package in MNCH was greatly appreciated by majority of clients attending the service;
“…... discrimination is not my concern for the past two years after the adoption of Option B+. I am confident enough to attend my follow up visit together with HIV negative mothers in underlined MNCH continuum of care. This is because; we all received our follow up care in one room and with the same health professional and this is a good opportunity for us. Therefore, I preferred this service package rather than previous vertically standalone PMTCT service in ART unit” (PMTCT client).
Immediate ART initiation regardless of CD4 count: overall, elimination of CD4 assessment as a requirement for ART treatment initiation for Option B+ in MNCH unit was highly accepted and acknowledged among different participant groups;
“……Before the introduction of Option B+ PMTCT high lost (3%) and dropout rate (4%) was documented in our facility. The main reason forwarded by majority of the clients was repeated appointments for CD4 count to assess illegibility criteria for initiating ART but after its adoption, patient retention to HIV chronic care was increasing” (PMTCT service provider).
Simplicity of ARV drug regimen (B+): Easy administration of one tablet per day of TDF+3TC+EFV for the woman during pregnancy, labour and delivery made easier when compared with the previous Option A or B that make patients easily adhere to the drug as described by majority of service providers and women;
“…... the drug provided for me during PMTCT visit was comfortable and easy to use. I selected a fixed time at 7:00 PM and I have been taking the drug usually with a specified time and I don’t want to miss even a fraction of seconds” (PMTCT client).
“……During the time of Option A and B, multiple ARV drugs were prescribed and patients were complained about the situation but now patient were easily adhere to the regimen and no more need of continuous adherence support”(PMTCT service provider).
Factors attributed to bad process service quality
Poor adherence to service standards: Majority of service providers had good experience regarding Option B+. However, one health care provider from one studied health facility reported her experience of considering CD4 count as criteria for initiating ART.
“…... I am not aware of prescribing ARV drugs regardless of CD4 count and I appointed two PMTCT clients for CD4 investigation before prescribing the drug”(PMTCT provider).
Workload: during an in-depth interview , some service providers had complained integration of Option B+ to MNCH service unit as it created patient load since no more health professional was appointed considering its integration to MNCH continuum of care ;
“…... before the introduction of Option B+ mother living with HIV were under follow up in ART clinic but now they had been enrolled in MNCH clinic during their maternal and child health care visit which resulted additional work load in our health facility” (PMTCT provider).
Prolonged waiting time: with similar finding to quantitative finding, majority of women reported their concern about long waiting time to get the service and a challenge that making them reluctant to come back;
“…... my great concern during my PMTCT follow up visit was issue of timing to get the service on time since there was delayed service as a result I have been thinking to miss the opportunity”(PMTCT client).
Table 2: Health facilities not fulfilling 90% of process service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12].
Process quality items
|
No of facilities
|
Percent
|
Facility suitable opening hour
|
8
|
66.7
|
Client greeting and welcoming
|
7
|
58.3
|
Introducing himself to clients
|
7
|
58.3
|
Waiting time to the counselor
|
6
|
50
|
Adequacy of counseling session
|
6
|
50
|
Counselor confidence during counseling
|
7
|
58.3
|
Conduct history taking
|
8
|
66.7
|
Conduct physical examination
|
8
|
66.7
|
Screening for opportunistic infection
|
8
|
66.7
|
Discus issues of reproductive health
|
8
|
66.7
|
Support for disclosure
|
7
|
58.3
|
Reviewing need of partner notification
|
7
|
58.3
|
Reviewing ARV drug adherence
|
7
|
58.3
|
Reviewing about safe sex practice
|
8
|
66.7
|
Reviewing of HIV infection
|
8
|
66.7
|
Screening for substance abuse
|
6
|
50
|
Discus issues of psychosocial support
|
7
|
58.3
|
Counseling for nutritional support
|
8
|
66.7
|
Screening for STI
|
8
|
66.7
|
Screening for cervical cancer
|
8
|
66.7
|
Calling clients by name
|
6
|
50
|
Encouraging women to ask questions
|
6
|
50
|
Reviewing mothers understanding
|
6
|
50
|
Conduct child growth assessment
|
7
|
58.3
|
Review issues of child immunization
|
8
|
66.7
|
Reviewing issues of infant feeding
|
8
|
66.7
|
Initiating cotrimoxazole therapy
|
9
|
75
|
Review TB risk assessment
|
8
|
66.7
|
Conduct virological test at 6 weeks of age
|
6
|
50
|
Conduct anti-body test at 18 months of age
|
6
|
50
|
As an Option B+ service output, majority; 91.7% of mother infant pair were alive and in their first line recommended treatment regimen in the past one year. However; high DBS result turnaround time and low patient satisfaction level were vital issues needed great attention while the service has been provided (Table 3).
Factors attributed to good output service quality
High patient retention: client’s belief in the efficacy of ARVs to prevent transmission improvement of their health status, confidentiality, absence of stigma and discrimination, and positive women-health worker relationships were facilitators for high patient retention of women to HIV chronic care after the introduction of Option B+ PMTCT.
“…... before the introduction of option B+ high patient lost and drop out were documented but now Option B+ was highly accepted by patents” (PMTCT service provider).
Factors attributed to bad output service quality
High turnaround time of DNAPCR virological test result: big issue forwarded by almost all participants was high turnaround time for DNAPCR virological test result communication. Majority, of clients attending the service suggested that DNAPCR result was arrived at the health facility from the central testing unit within 4-6 months time period as explained below;
“…... I am always worried regarding delay of my new borne baby’s HIV virological test result. As you have seen, am receiving exposed infant test result today after six month. Unfortunately, I am very much happy today since his result non-reactive. But the past six months were painful for me” (PMTCT client).
Non-functionality of DBS analyzer machine: as described by most of the service providers, the reason forwarded by experts from the central testing unit for result delay was DBS analyzer machine was frequently non-functioning ;
“…... I am always communicating using phone with laboratory experts in the central testing unit an issue of DBS result delay but they told me that the machine was under maintenance” (PMTCT Service provider).
Table 3: Health facilities not fulfilling 90% of output service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia [N=12].
Output quality items
|
No of facilities
|
Percent
|
Client satisfaction per standard
|
7
|
58.3
|
Clients with good treatment adherence
|
8
|
66.7
|
Clients involved partner testing
|
5
|
41.7
|
Early infant diagnosis for virological test
|
6
|
50
|
Confirmatory antibody test
|
7
|
58.3
|
DBS result turnaround time per standard
|
4
|
33.3
|
Enrolling HIV positive pediatrics to HIV chronic care
|
8
|
66.7
|
Perform CD4 count as base line during their initial visit
|
7
|
58.3
|
Perform CD4 count at least one as follow up visit
|
6
|
50
|