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).
[Figure 2]
Table 1: Summarized themes that emerged from the data analysis and their relationship to the predetermined categories that are reflective of Donabedian’s model.
Categories
|
Themes
|
Sub-themes
|
Input service quality
|
Theme 1: Reasons for good input quality
|
Good partnership
|
|
Theme 2: Reasons for bad input quality
|
Resource constraint
|
Process service quality
|
Theme 1: Reasons for good process quality
|
Service integration
|
|
|
ART initiation regardless of CD4 count
|
|
|
Simplicity of ARV drug regimen
|
|
Theme 2: Reasons for bad process quality
|
Poor service compliance
|
|
|
prolonged waiting time
|
|
|
Work load
|
Output service quality
|
Theme 1: Reasons for good output quality
|
Patient retention
|
|
Theme 2: Reasons for bad output quality
|
high DBS result turnaround time
|
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 (additional file one). 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 2).
Table 2: 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
|
Theme 1: Reasons for good input quality
Majority of service providers recognized that building team work among program directors and district level experts enabled them to identify availability related factors on time. This is an identified contributing facilitator for facilities to be judged providing good input service quality (Figure 1). This is illustrated clearly by the following service provider:
“…... we have been conducted weekly meetings with program managers and district level experts with availability related factors and prepare an action plan to resolve input related constraints on time” (PMTCT service provider ≠12 ).
Theme 2: Reasons for bad input quality
Consistent with quantitative findings (Table 1), health workers expressed their opinion on shortage of trained human workforce and supply chain issues for Option B+ as a barrier for input related factor. Sometimes, trained staffs were also preferred to serve health care services other than MNCH unit as described below:
“……Imagine only two health care providers trained on Option B+ and serving more than an average of 80 clients per day. Having this reality, how can we provide quality? Therefore, without allocating appropriate number of trained health care providers , only integrating the service to MNCH unit may not be successful” (PMTCT service provider ≠4).
“……Some drug list used for opportunistic infection such as co-trimoxazole prophylactic therapy was reported as stock out for more than six months in the past year lack of transportation was a reason given for us when requested ”(PMTCT service provider≠8 ).
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 included 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 service consultation (Table 3).
Table 3: 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
|
Theme 1: Reasons for good process quality
Task shifting to scale up Option B+ by integrating the delivery of Option B+ ART initiation as one service package in MNCH unit, initiation of ARV regardless of CD4 count, and simplicity of ARV regimen was greatly appreciated by majority of service providers and clients during an interview:
“…... 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 MNCH clinic. This is because; we all received our follow up care in one room and with the same health professionals” (PMTCT client ≠ 18).
“……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 for ART initiation but after its adoption, patient high patient retention was documented ” (PMTCT service provider ≠ 2).
“…... 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≠ 21).
“……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 ≠5).
Theme 2: Reasons for bad process quality
Majority of service providers had good experience regarding Option B+. However, one health care provider reported her experience of considering CD4 count as criteria for initiating ART which resulted poor service compliance with service standards. Some other providers criticized its integration as creating workload and prolonged waiting time as described as follows:
“…... 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 service provider ≠10 ).
“…... 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 service provide≠3).
“…... 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 ≠19).
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 which needed great attention while the service has been provided (Table 4).
Table 4: 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
|
Theme 1: Reasons for good output quality
As described by majority of service providers, client’s belief in the efficacy of ARVs, absence of stigma and discrimination were facilitators for high patient retention as articulated below:
“…... 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 provide≠5).
Theme 2: Reasons for bad output quality
Big issue forwarded by almost all participants was high turnaround time for DNAPCR virological test result communication which was arrived within 4-6 months time period at the health facility from the central testing unit 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 ≠28).
“…... I am always communicating using mobile 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≠ 7).