Whereas stewardship from the NTP improved district TB service delivery, stewardship from local government (LG) was weak despite existence of memorandum of understanding between LGs and NTP. Effective bureaucratic relationship between state and LG TB programmes in this study contradicts evidence of poor stewardship in India, Ghana and South Africa (7, 12, 24). In our setting, accountability relationship was enhanced by programme management support, supportive supervision and quarterly performance review meetings. Nevertheless, the weak stewardship from the LG confirms previous evidence that TB control program is perceived as less important than other public health programmes (20, 23) but contrasts evidence of strong political commitment from district governments in Pakistan (8). Unmet expectation of local officials of financial incentives from NTP and perception that partners support TB control explained low responsiveness of LGs. Since governance affects input and process of TB control, LG officials need to strengthen stewardship of and become more responsive to TB control program.
This study also found that government spending on TB control was inadequate, which is similar to evidence from several studies where donors, instead of governments, drive TB control efforts (5-13). In this study, non-release of budgeted funds at the state-level and complete absence of TB in LG budgets resulted in persisting TB funding gap and unlikelihood of sustainability of TB control. As external funding declines, all tiers of government in Nigeria need to improve financing of TB control through budgets. Also, Nigeria’s efforts to decentralise social health insurance to states presents an opportunity to include TB in social health insurance schemes (14, 15), given that Nigerian TB patients incur catastrophic costs (36, 37). Moreover, it might be helpful to consider medical vouchers and subsidies for poor TB patients (17, 18).
This study’s findings revealed that poor human resources management practices and inadequate training of TB service providers hindered TB control. These findings are consistent with lack of skilled staff (4, 10, 11, 22); lack of incentives for TB service providers (5, 10); inadequate training (10, 11, 19); and poor attitude and weak commitment of health workers towards deployment to TB services (22, 23). In contrast, evidence from European countries show that skilled and motivated healthcare workers enabled TB control (16). Strategies that aim at improving TB control workforce must address shortages of staff, stigma by health workers and lack of incentives to TB service providers. Additionally, broad contextual factors underlying human resource crisis especially social restriction to deployment of female health workers and delayed payment of staff salaries warrant attention of decision makers.
The findings revealed that TB service providers have poor capacity for recording and reporting TB data due to mismatch between changes in tools and training of service providers, which is similar to evidence from Ethiopia and Nigeria (5, 22). Even though, changes in tools were adaptation to new developments in TB control program, lack of training meant that TB service providers did not completely fill tools and required constant supportive supervision. A strategy to improve data management was introduction of electronic recording and reporting system. However, experiences from South Africa suggest that operational challenges limited effectiveness of electronic recording and reporting system (14). Nigeria’s NTP would need to improve on-the-job capacity building of service providers on data management, while addressing the limitations of electronic recording and reporting system.
The findings of this study that drugs and other supplies to TB treatment centres were interrupted are consistent with evidence of shortages of TB drug and laboratory supplies elsewhere (7, 11, 22), but contrast evidence of effective supply and drug management in Pakistan (8). Although use of dedicated logistics agency to distribute TB drugs improved TB drug supply system (9, 22), experiences in our study area reveal that TB drugs for an entire district were often dumped in one health facility. Equally, absence of drug kits tailored to extrapulmonary TB patients and TB patients weighing 70kg and above. Hence, service providers must augment one drug kit to meet their dosage requirements, which depletes the stock. Sustainable TB drug supply system would entail strengthening the logistics agency and improving the capacity of NTP to forecast TB drug needs.
Weak TB service delivery system was found as a key constraint to TB control. Consistent with findings of previous studies (5, 29, 30), integration of TB into general health services was weak. Social stigma and concern for contracting TB meant that health workers refuse deployment to and participation in TB control programmes. Also, the findings of weak laboratory capacity due to lack of space, damaged microscopes, attrition of laboratory staff and operational challenges of GeneXpert, are like evidence from previous studies (5, 11, 14, 22, 23, 26, 27). Equally, poor involvement of community volunteers and patent medicine vendors due to withdrawal of financial incentives hindered TB service delivery. Although TB service providers have used electronic reminders to improve treatment adherence similar to China’s experience (17), weak patient tracking systems resulted from poor funding and lack of transportation. Notwithstanding existence of guidelines for TB/HIV integration, weak TB/HIV collaboration is similar to evidence from other studies (10, 12, 14, 24, 28). Policies to improve TB service delivery system must address stigma among health workers, strengthen laboratory capacity, incentives to community volunteers and patent medicines vendors, improve funding of patient tracking and bolster TB/HIV integration.
This study adds to the growing scholarship using health systems lens to examine disease control programmes. Particularly, application of systems thinking provided useful analytical tool to explain how health system strengthening enables or constrains TB control in high TB burden, low-resource settings. However, as the participants were limited to frontline, district-level TB service providers in one sub-national context, the findings may not be generalizable to other settings. Nonetheless, this study does not aim to generalize but to provide evidence to inform policy changes to ensure universal access to TB services in low-resource settings facing similar approaches. Given the emphasis on people-centred health system, perceptions and experiences of consumers TB service delivery systems would be an area of future research.