American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) ISSN (Print) 2313-4410, ISSN (Online) 2313-4402 © Global Society of Scientific Research and Researchers http://asrjetsjournal.org/ Tuberculosis Service Provision in Ethiopia: Health Facility Assessment Theodros Getachewa*, Abebe Bekeleb, Atkure Defarc, Mekonnen Tadessed, Habtamu Tekliee, Kassahun Amenuf, Terefe Gelibog, Yibeltal Assefah, Amha Kebedei a,b,c,d,e,f,g,h,j Ethiopian Public Health Institute (EPHI), Addis Ababa, P.O.Box 1242, Ethiopia aEmail: tedi.getachew@yahoo.com bEmail: abebe1277belay@gmail.com cEmail: atid1999@yahoo.com dEmail: mekonnta@yahoo.com eEmail: habtamuteklie2@yahoo.com fEmail: kassishg2@yahoo.com gEmail: mamater1986@gmail.com hEmail: yibeltala@ephi.gov.et iEmail: amhak@ephi.gov.et Abstract The major objective of the survey is to assess the availability and preparedness of health facilities in Ethiopia to provide quality Tuberculosis services. The survey was part of the 2014 Ethiopia Service Provision Assessment Plus Survey. A total of 1,327 health facilities were assessed. The results shows that more than two out of three (69%) facilities excluding health posts in Ethiopia offer any TB diagnostic, treatment or/and treatment follow up services. Among all health posts, 29% of them offer any TB diagnostic services and any treatment and/or treatment follow up services. Six in ten (59%) of facilities excluding health posts use sputum smear only to diagnose TB. Of those facilities offering any TB services more than half (60%) have trained staff. Among facilities excluding health posts offering any TB services, 44% have guidelines for diagnosis and treatment of TB, 18% have guideline for diagnosis and treatment of MDR-TB, and 9% have guideline for management of HIV and TB co-infection. ------------------------------------------------------------------------ * Corresponding author. E-mail address: tedi.getachew@yahoo.com. 145 http://asrjetsjournal.org/ American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 As a conclusion we can say that any TB diagnostic, treatment or/and treatment follow up services is available in more than half of the facilities in Ethiopia excluding health post. Half of the health facilities in Ethiopia excluding health post have guidelines for diagnosis and treatment of TB. Keywords: TB service provision; SPA+; Ethiopia. 1. Introduction The major health problems of the country remain largely preventable communicable diseases, reproductive health related problems and nutritional disorders. Despite major progresses have been made to improve the health status of the population in the last two decades, Ethiopia’s population still face a high rate of morbidity and mortality and the health status remains relatively poor. Figures on vital health indicators from EDHS 2011 show a life expectancy of 54 years (53.4 years for male and 55.4 for female), and an IMR of 59/1000 [1]. There are multiple components that will influence this: available infrastructure; staff deployment and presence; and availability and quality of services provided. Although routine reporting will contribute to this understanding, at this stage of the implementation of routine reporting, national surveys are required to further complement the available routine reporting. The Federal Ministry of Health (FMoH) included monitoring and evaluation as an invaluable component of HSDP IV [2]. It is technically impossible to obtain all health and health related data exclusively through HMIS, conducting regular surveys is crucial to capture selected set of data and triangulate various sources in order to improve the accuracy of health interventions. The state of health in a country can be measured through indicators describing long-term program achievements and effects on the populations. Health Facility Assessments (HFA) or Health Facility Surveys (HFS) provide objective information of the preparedness of health facilities to provide the services required by the population. Thus, selected indicators need to be measured to obtain data on the facilities, supplies, and services for informed decision-making. Sound information on the supply and quality of health services is necessary for health systems management, monitoring and evaluation. Efforts to achieve the Millennium Development Goals (MDGs) and to scale up interventions for HIV/AIDS, malaria, safe motherhood and child health through global health partnerships, have drawn attention to the need for strong country monitoring of health services, covering the public, private-for- profit and private not-for-profit sectors, and their readiness to deliver key interventions. With the increased demand for accountability and the need to demonstrate results at country and global levels, information is needed to track how health systems respond to increased inputs and improved processes over time, and the impact such inputs and processes have on improved health outcomes and better health status. However, despite heightened investments in health systems, few countries have up-to-date information on the availability of health systems that covers both the public and private sectors. Fewer still have accurate, up-to- date information required to assess and monitor the "readiness" of health facilities to provide quality services. 146 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 Ensuring access to quality health services is one of the main functions of a health system. Service access includes different components: availability, which refers to the physical presence or reach of the facilities; affordability, which refers to the ability of the client to pay for the services; and acceptability, which refers to the sociocultural dimension. The quality of services is yet another dimension. A prerequisite to service quality is service readiness, i.e. the health facilities should have the capacity to deliver the services offered. This capacity includes the presence of trained staff, guidelines, infrastructure, equipment, medicines and diagnostic tests. Service availability and readiness are prerequisites to quality services, but do not guarantee the delivery of quality services. Ethiopia is one of the 22 high burden countries (HBCs) in the world high incidence and prevalence of TB [3]. The national population based TB prevalence survey conducted in 2010/11 revealed that the prevalence of smear positive TB among adults and all age group was found to be 108 and 63 per 100,000 populations, respectively. The prevalence of bacteriologically confirmed TB was found to be 156/100,000 populations and by extrapolations, the prevalence of all forms of TB in Ethiopia is estimated to be 240/100,000 populations [4]. According to the FMOH 2013/14 annual performance report of Ethiopia, in 2013 it was planned to start TB case management at health post (HP level) and to increase the number of facilities that treat Multi-Drug Resistant Tuberculosis (MDR-TB) [5]. The report indicated that TB treatment success rate (TSR) showed a slight increase from 90.6 percent in 2012 to 91.4 percent in 2013 (below the target of 95 percent set for that year), while TB cure rate increased from 68.2 to 70.3 percent in the same period (below the target of 79 percent set for 2013) [5]. However, despite this result, constant efforts and resources should be ensured to address the remaining challenges and sustain achievements. To build on the achievements of DOTS and address the remaining challenges, the STOP TB strategy was launched by WHO in 2006 to help achieve the millennium development goals or TB in 2015 [6, 3]. Ethiopia also adopted this strategy to achieve the national TBL and TB/HIV targets [5]. 2. Objective The major objective of the survey is to assess the availability and preparedness of health facilities in Ethiopia to provide quality tuberculosis services. 3. Methodology 3.1 study design and location This study is part of the Ethiopian Service Provision Assessment Plus (SPA+) and it is a cross-sectional study, which combine MEASURE DHS SPA, World Health Organization’s service Availability and Readiness Assessment (SARA) and the World Bank’s Service Delivery Indicator (SDI). The sample size for the study was determined by a combination of census and random samples. 147 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 Information was collected from a representative sample of facilities managed by the government, non- governmental organisations (NGOs), and private for-profit organisations, in all 9 regions and 2 city administrations of the country to provide a comprehensive picture of the strengths and weaknesses of the service delivery environment for each assessed service. This study provide indicators at national level for the different facility types and managing authority as well as aggregate indicators at the regional level. 3.2 data collection instrument To achieve the objectives of the assessment and to capture information from the different categories, data were collected using the following instruments: A facility inventory questionnaire was used to obtain information on how the facilities are prepared to provide each of the priority services. A health provider questionnaire was used to solicit information from a sample of health service providers on their qualifications (training, experience, and continuing education), supervision they had received, and their perceptions of the service delivery environment. The tools were developed for all facility types except for health posts, this could be a limitation of the study. 3.3 Data Collection Approaches After preparation of definitive questionnaires in English, the questionnaires were translated into Amharigna. English and Amharigna translation of the inventory questionnaire were loaded onto tablet computers, which were used during interviews to ask questions and also record responses (computer assisted personal interviewing–CAPI). 3.4 Sampling The sample for the survey was a stratified random sample designed to provide representative results for Ethiopia, for different facility types and different management authorities, and for each of the 11 regions of the country. The formula used for the sample size calculation is given by ( ) p pn 2 1 ε − = where ε is the requested relative standard error for estimating a proportion p . 148 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 Because of their importance and their limited numbers, all hospitals were included in the survey and allowing for inclusion of newly identified hospital in the survey. A representative sample of health centres and clinics were selected and included in the survey. A total sample size of 1,327 health facilities were selected, including 321 health posts and 10 newly identified hospitals. Health posts were independently selected, analysed, and reported. 3.5 Training and Data Collection Pre-Test The questionnaires were pretested to detect any possible problems in the flow of the questionnaires, gauge the length of time required for interviews, as well as any problems in the translations. The pretest also helped to detect any problems with the data entry programs. Main Assessment The main training for the survey took place from February 06, 2014 – March 09, 2014. Main data collection took place from March 10, 2014, to July 25, 2014. The team leader had responsibility of checking all questionnaires before leaving the facility. Each team was given a list of facility to visit, list of facilities name, type, and location. 3.6 Data management and analysis The information entered in the PC-tablets by each interviewer was downloaded daily by the team supervisor into his/her computer, and sent regularly to the central office (EPHI), preferably when data collection was completed in a health facility. Conventions were observed during the analysis of the survey data. Unless otherwise indicated, the report considered only those items observed by the interviewers themselves to be available. 3.7 Ethical clearance Ethical clearance was obtained from the Institutional Review Board of Scientific and Ethical Review Office (SERO) of EPHI. Copies of letter of approval by SERO was presented to regional health bureaus. On top of that, informed consent was obtained from the facility in-charge, from all respondents for the facility inventory questionnaires, and from interviewed providers. 4. Result 4.1 Availability of tuberculosis diagnosis and management services 4.1.1 Availability of tuberculosis Diagnosis services 149 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 Overall, more than two out of three (69 percent) facilities excluding health posts in Ethiopia offer any TB diagnostic, treatment or/and treatment follow up services where 67 percent have any TB diagnostic services using different methods like clinical symptoms, sputum smear, x-ray, both sputum smear and x-ray or either of the two. Almost all referral hospitals (97 percent) reports that providers in the facility make a diagnosis of TB by using any of the following methods: sputum smear only, X-ray only, either sputum or X-ray, both sputum and X-ray, based on clinical symptoms only, sputum culture, or molecular tests; or else the facility reports that they refer clients outside the facility for TB diagnosis, and a register was observed indicating clients who had been referred for TB diagnosis. However, screening and referral for TB diagnosis is 38 percent. Almost all General hospitals (97 percent) reports that providers in the facility make a diagnosis of TB by using any of the following methods: sputum smear only, X-ray only, either sputum or X-ray, both sputum and X-ray, based on clinical symptoms only, sputum culture, or molecular tests; or else the facility reports that they refer clients outside the facility for TB diagnosis, and a register was observed indicating clients who had been referred for TB diagnosis. However, one third of the General hospitals offer screening and referral for TB diagnosis. Almost all Primary hospitals (98 percent), nine of ten health centers, and three in ten health posts report that providers in the facility make a diagnosis of TB by using any of the following methods: sputum smear only, X- ray only, either sputum or X-ray, both sputum and X-ray, based on clinical symptoms only, sputum culture, or molecular tests; or else the facility reports that they refer clients outside the facility for TB diagnosis, and a register was observed indicating clients who had been referred for TB diagnosis. Screening and referral for TB diagnosis in primary hospitals, health centers, and health posts is 40 percent, 39 percent, and 29 percent respectively. Higher clinics (87 percent) and medium clinics (82 percent) reports that providers in the facility make a diagnosis of TB by using any of the following methods: sputum smear only, X-ray only, either sputum or X-ray, both sputum and X-ray, based on clinical symptoms only, sputum culture, or molecular tests; or else the facility reports that they refer clients outside the facility for TB diagnosis, and a register was observed indicating clients who had been referred for TB diagnosis. Of all health facilities excluding health posts, 23 percent reported that they screen and refer the clients outside the health facility for TB diagnosis. Government health facilities are more likely to provide TB diagnostic services (91 percent) than private for profit (40 percent) facilities. At the regional level, facilities in Addis Ababa (91percent), Harari (84 Percent), Dire Dawa (82 percent), and Tigray (80 percent) regions are more likely to offer TB diagnostic services (Table 1). Among all health posts, 29 percent of them offer any TB diagnostic services and any treatment and/or treatment follow up services. The same percentage (29 percent) of health posts reported that they screen and refer the client outside the facility for TB diagnosis. At regional level, health posts in Afar and Somali regions reported 150 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 that they offer neither any TB diagnostic, treatment and/or treatment follow up services nor screening and referral services for TB diagnosis. Among all health posts offering any TB services, 65 percent had at least one provider reported receiving in-service training relevant to particular TB treatment during the last 24 months preceding the survey. Table 1: Availability of tuberculosis services, guidelines, and trained staff for tuberculosis services Among all facilities excluding health posts, the percentages offering any tuberculosis (TB) diagnostic services or any treatment and/or treatment follow-up services and, among facilities offering any TB services, the percentages having TB guidelines and at least one staff member recently trained in TB services, by background characteristics, Ethiopia SPA+ 2014 Percentage of all facilities offering: Percentage of facilities offering any TB services that have guidelines for: Background characteristics Screening and referral for TB diagnosis 1 Any TB diagnostic services 2 Any TB treatment and/or treatment follow-up services 3 Any TB diagnostic, treatment and/or treatment follow-up services 3 Number of facilities Diagnosis and treatment of TB Diagnosis and treatment of MDR- TB Management of HIV and TB co- infection TB infection control Trained staff 4 Number of facilities offering any TB diagnostic, treatment and/or treatment follow-up services Facility type Referral Hospital 38 97 84 97 2 77 55 0 35 81 2 General Hospital 33 97 85 98 7 68 35 7 24 79 7 Primary Hospital 40 98 92 98 3 69 45 8 22 76 3 Health Center 39 91 91 95 182 54 21 9 11 71 173 Higher Clinic 18 87 32 87 13 37 19 13 29 59 11 Medium Clinic 11 82 15 82 37 15 7 13 14 26 30 Lower Clinic 2 22 1 22 119 5 0 5 10 16 26 Managing authority Government/public 39 91 91 95 190 55 22 8 12 72 181 Other governmental (military, prison, federal police) 6 62 11 62 2 9 9 0 0 14 1 Private for profit 5 40 6 40 163 16 7 11 16 27 65 NGO (mission/faith- based, nonprofit) 27 63 42 63 8 36 23 2 4 73 5 Region Tigray 32 80 66 84 22 61 31 8 18 57 18 Afar 33 60 49 63 5 59 6 0 8 59 3 Amhara 14 63 52 66 87 58 24 11 19 72 58 Oromia 33 62 60 64 116 49 14 8 8 70 75 Somali 20 73 55 73 8 35 3 1 5 48 6 Benishangul Gumuz 6 44 47 51 4 69 25 13 3 72 2 SNNP 22 73 48 74 80 28 15 7 8 51 60 Gambella 6 15 12 16 6 25 10 19 19 63 1 Harari 14 91 46 91 2 44 25 9 16 53 2 Addis Ababa 20 84 22 84 31 26 20 15 20 31 26 Dire Dawa 26 82 64 82 3 61 22 5 20 73 2 Urban/rural Urban 19 70 39 70 149 45 23 8 19 53 105 Rural 26 66 60 69 214 44 15 10 8 65 147 151 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 Total 23 67 51 69 363 44 18 9 13 60 252 Note: The guidelines and trained staff indicators presented in this table comprise the staff and training domain for assessing readiness to provide TB services within the health facility assessment methodology proposed by WHO and USAID (2012). Note: MDR-TB = multi-drug resistance tuberculosis 1 Facility reports that it refers clients outside the facility for TB diagnosis, and there is documentation on the day of the survey visit to support the contention. 2 Facility reports that providers in the facility make a diagnosis of TB by using any of the following methods: sputum smear only, X-ray only, either sputum or X-ray, both sputum and X-ray, based on clinical symptoms only, sputum culture, or molecular tests; or else the facility reports that they refer clients outside the facility for TB diagnosis, and a register was observed indicating clients who had been referred for TB diagnosis. 3 Facility reports that they follow one of the following TB treatment regimens or approaches: · Directly observe for two months and follow up for four months · Directly observe for six months · Follow up clients only after the first two months of direct observation elsewhere · Diagnose and treat clients while in the facility as inpatients, and then discharge elsewhere for follow-up · Provide clients with the full treatment with no routine direct observation phase · Diagnose, prescribe, or provide medicines with no follow-up 4 At least one interviewed provider of any one of the following TB services reported receiving in-service training relevant to the particular TB service during the 24 months preceding the survey: TB diagnosis and treatment; management of HIV and TB co-infection; MDR-TB treatment, identification of need for referral; or TB infection control. The training must have involved structured sessions; it does not include individual instruction that a provider might have received during routine supervision. Common Diagnostic methods for PTB Six in ten (59 percent) of facilities excluding health posts have the capacity to stain sputum for TB diagnosis. Even though the guideline did not allow, 7 percent of lower clinics reported to have the capacity to stain sputum for TB diagnosis. Among all health facilities offering any TB diagnostic, treatment or/and treatment follow up services, half of primary hospitals, 67 percent of health centres, 55 percent of higher clinics, and 71 percent medium clinics have the capacity to stain sputum for TB diagnosis (Figure 1). Figure 1: Common methods used for diagnosis of pulmonary TB among facilities, excluding health posts, offering any TB services, ESPA+2014 59 0 60 7 23 0 10 20 30 40 50 60 70 Sputum smear only X-ray only Either sputum or x-ray Both sputum and x-ray Clinical symptoms only Percentage 152 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 4.1.2 Availability of Tuberculosis Management Services Facilities report that one of the following treatment approaches; directly observe for two months and follow up for 4 months, directly observe for six months or follow clients only after the first two months of direct observation elsewhere or treat clients while in the facility as inpatient. According to the definition, TB treatment or follow up service is available in half (51 percent) of all facilities excluding health posts, including 92 percent of primary hospitals, 91 percent of health centres and 32 percent of higher clinics. Government health facilities are more likely to offer treatment or follow up service (91 percent) than private for profit facilities (6 percent). At regional level, facilities in Tigray (66 percent) and Dire Dawa (64 percent) regions are more likely to offer treatment and/or follow up services than facilities in Addis Ababa and Gambella regions (22 and 12 percent), respectively. 4.2 Readiness to Provide Quality Tuberculosis Services 4.2.1 Availability of guidelines and trained staff for TB Services Among facilities excluding health posts offering any TB services, 44 percent have guidelines for diagnosis and treatment of TB, 18 percent have guideline for diagnosis and treatment of MDR-TB, and 9 percent have guideline for management of HIV and TB co-infection. Of those facilities offering any TB services more than half (60 percent) have trained staff (Table 2). Government health facilities are more likely to have PTB and MDR –TB treatment guidelines than private facilities. Among facilities offering any TB services, six out of every ten facilities report that they have at least one provider of TB who received in-service training during the 24 months preceding the survey. These in- services trainings include TB diagnosis and treatment or management of HIV/TB co-infection or MDR-TB treatment or identification of need for referral or TB infection control at health facility. At national level, two-third (65 percent) of health posts offering any TB diagnostic, treatment and/or follow up services reported that they have at least one provider trained on TB. Table 2: Availability of tuberculosis services, guidelines, and trained staff for tuberculosis services at health post Among all health posts, the percentages offering any tuberculosis (TB) diagnostic services or any treatment and/or treatment follow-up services and, among health posts offering any TB services, the percentages having TB guidelines and at least one staff member recently trained in TB services, by background characteristics, Ethiopia SPA+ 2014 Percentage of all health posts offering: Percentage of health posts offering any TB services that have guidelines for: Background characteristics Screening and referral for TB diagnosis 1 Any TB diagnostic services 2 Any TB diagnostic, treatment and/or treatment follow-up services 3 Number of facilities TB infection control Trained staff 4 Number of health posts offering any TB diagnostic, treatment and/or treatment follow-up 153 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 services Facility type Health Post 29 29 29 802 3 65 233 Managing authority Government/public 29 29 29 800 3 65 233 Other governmental (military, prison, federal police) 0 0 0 2 - - 0 Region Tigray 12 12 12 33 0 33 4 Afar 0 0 0 10 - - 0 Amhara 34 34 34 182 0 58 62 Oromia 30 30 30 316 8 62 93 Somali 0 0 0 31 - - 0 Benishangul Gumuz 7 7 7 17 0 100 1 SNNP 34 34 34 205 0 77 70 Gambella 4 4 4 4 0 100 0 Harari 29 29 29 1 0 83 0 Dire Dawa 45 45 45 2 14 21 1 Urban/rural Urban 28 28 28 26 0 99 7 Rural 29 29 29 776 3 64 225 Total 29 29 29 802 3 65 233 Note: The guidelines and trained staff indicators presented in this table comprise the staff and training domain for assessing readiness to provide TB services within the health facility assessment methodology proposed by WHO and USAID (2012). 1 Facility reports that it refers clients outside the facility for TB diagnosis, and there is documentation on the day of the survey visit to support the contention. 2 Facility reports that providers in the facility make a diagnosis of TB by using any of the following methods: sputum smear only, X-ray only, either sputum or X-ray, both sputum and X-ray, based on clinical symptoms only, sputum culture, or molecular tests; or else the facility reports that they refer clients outside the facility for TB diagnosis, and a register was observed indicating clients who had been referred for TB diagnosis. 3 Facility reports that they follow one of the following TB treatment regimens or approaches: · Directly observe for two months and follow up for four months · Directly observe for six months · Follow up clients only after the first two months of direct observation elsewhere · Diagnose and treat clients while in the facility as inpatients, and then discharge elsewhere for follow-up · Provide clients with the full treatment with no routine direct observation phase · Diagnose, prescribe, or provide medicines with no follow-up 4 At least one interviewed provider of any one of the following TB services reported receiving in-service training relevant to the particular TB service during the 24 months preceding the survey: TB diagnosis and treatment; management of HIV and TB co-infection; MDR-TB treatment, identification of need for referral; or TB infection control. The training must have involved structured sessions; it does not include individual instruction that a provider might have received during routine supervision. 4.2.2 Diagnostic capability and availability of medicines for treatment of Tuberculosis Among facilities excluding health posts offering TB diagnosis, treatment and/or follow up services, 52 percent have diagnostic capacity using TB smear microscopy, while very few reported having TB x-ray (6 percent) and rapid diagnostic test kits (2 percent). On the other hand, only 3 percent of referral hospital and 1 percent general hospitals have TB diagnostic capability using culture medium. Regarding availability of quality control system, 154 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 11 and 12 percent of the facility have internal quality (IQ) and External quality (EQ) control system of sputum smear, respectively, while 24 percent have both systems. Among all health facilities excluding health post providing TB diagnosis, treatment and/or follow up services, 67 percent have all first-line TB medicines available. Most of the hospitals (87 percent referral, 82 percent general, and 92 percent primary), and health centers (88 percent) provide all first-line medicines, while only in less than 15 percent of (higher, medium and lower) clinics, all first-line medicines were available for TB treatment. At the regional level, among facilities providing TB diagnosis, treatment and/or follow up services, Benishangul Gumuz (94 percent), Oromia (83 percent), Gambella (82 percent) and Tigray (80 percent) regions are more likely to have all first-line drugs (Table 3). Among all health posts providing any TB diagnostic, treatment and/or treatment follow up services, only 15 percent had HIV diagnostic capacity. At region level, facilities in Dire Dawa region (79 percent) is more likely to have HIV diagnostic capacity. Table 3: Diagnostic capacity and availability of medicines for tuberculosis treatment Among facilities, excluding health posts, offering any tuberculosis (TB) diagnostic, treatment and/or treatment follow-up services, the percentages that have TB and HIV diagnostic capacity and medicines for TB treatment available in the facility on the day of the survey, by background characteristics, Ethiopia SPA 2014 Percentage of facilities that have the following TB diagnostic capacity Percentage of facilities that have Percentage of facilities that have the following medicines for treating TB Background characteristics TB smear microsco py1 Culture medium2 Availabilit y of quality control system of sputum smear: EQ Availabilit y of quality control system of sputum smear: IQ Availabil ity of quality control system of sputum smear: Both TB rapid diagnostic test kits TB X-ray HIV diagnostic capacity3 System for diagnosin g HIV among TB clients4 First-line treatment for TB5 Injectable streptomycin Number of facilities offering any TB diagnostic, treatment and/or treatment follow-up services Facility type Referral Hospital 84 3 10 13 71 6 77 100 94 87 58 2 General Hospital 81 1 12 14 57 6 75 98 80 82 57 7 Primary Hospital 78 0 10 12 73 0 49 96 86 92 67 3 Health Center 54 0 15 11 27 1 0 95 81 88 42 173 Higher Clinic 81 0 11 22 32 7 43 70 39 14 3 11 Medium Clinic 56 0 7 15 6 0 3 46 19 15 0 30 Lower Clinic 2 0 0 0 1 0 0 17 7 2 0 26 Managing authority Government/ public 56 0 15 11 29 1 3 96 81 89 43 181 Other 18 0 0 0 14 0 9 100 14 18 5 1 155 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 governmental (military, prison, federal police) Private for profit 41 0 4 12 10 2 13 39 18 9 1 65 NGO (mission/ faith-based, nonprofit) 45 0 28 4 6 0 10 72 64 64 7 5 Region Tigray 69 0 8 21 41 0 7 94 77 80 52 18 Afar 65 0 9 0 38 4 6 87 61 74 25 3 Amhara 54 0 7 18 29 0 4 84 71 76 39 58 Oromia 49 0 12 8 26 2 4 93 81 83 31 75 Somali 44 0 12 7 3 0 9 81 41 61 37 6 Benishangul Gumuz 47 0 28 3 44 0 6 88 81 94 44 2 SNNP 40 0 19 3 15 1 2 72 51 58 27 60 Gambella 47 0 0 25 0 0 6 82 44 82 44 1 Harari 66 0 22 3 16 0 13 53 38 38 28 2 Addis Ababa 65 0 9 18 18 4 19 47 27 16 11 26 Dire Dawa 71 0 27 2 39 2 15 85 76 73 37 2 Urban/rural Urban 63 0 9 15 33 1 12 72 55 49 30 105 Rural 43 0 14 8 17 2 1 87 71 80 32 147 Total 52 0 12 11 24 2 6 80 64 67 31 252 Note: The indicators presented in this table comprise the diagnostics and medicines and commodities domains for assessing readiness to provide services for TB within the health facility assessment methodology proposed by WHO and USAID (2012). EQ = External quality, IQ = Internal quality, Both = availability of both External and Internal quality assessment 1 Functioning microscope, slides, and all stains for Ziehl-Neelson test (carbol-fuchsin, Sulphuric acid and methyl blue) all were available in the facility on the day of the survey visit. 2 Solid or liquid culture medium, e.g., MGIT 960 3 HIV rapid diagnostic test kits available, or ELISA with reader, incubator, and specific assay; or dynabeads with vortex mixer; or western blot 4 Record or register indicating TB clients who had been tested for HIV 5 Four-drug fix-dose combination (4FDC) available, or else isoniazid, pyrazinamide, rifampicin, and Ethambutol are all available, or a combination of these medicines, to provide first-line treatment Tuberculosis and HIV/AIDS Services In ESPA+ survey the availability of TB/HIV collaborative services were also assessed. Accordingly, among facilities excluding health posts offering any TB diagnostic, treatment, and/or follow up services, 80 percent have HIV diagnostic capacity and 64 percent of the facilities have a system in place for diagnosing HIV among TB clients. 4.2.3 Tuberculosis Infection Control Each facility should have a standard precaution and a set up conditions for client examination in the treatment of 156 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 TB patients. Among facilities providing TB diagnosis or/and treatment, less than half of the facilities have soap (44 percent) and running water (38 percent), while only 28 percent have both water and soap. Thirty percent of the facilities have alcohol based hand rubbing antiseptics and about 43 percent have either alcohol-based hand rubbing antiseptics or water and soap as infection control mechanism for treating TB clients. Similarly, the percentages of facilities with waste receptacle and medical mask on the day of data collection is 24 and 13 percent, respectively (Table 4). About one third of health centers (31 percent) and four of ten health posts (41 percent) have either soap and water or alcohol-based hand antiseptics. Government health facilities (37 percent) are less likely to have soap and water or alcohol-based hand antiseptics compared with facilities managed by private for profit (77 percent). Table 4: Standard precautions and conditions for client examination for tuberculosis treatment Facilities having standard precautions and conditions for client examination for tuberculosis treatment Background characteristics Soap Running water1 Soap and running water Alcohol- based hand antiseptic Soap and running water or else alcohol- based hand antiseptic Latex gloves2 Sharps container Waste receptacle3 Medical mask Number of facilities offering any TB diagnostic, treatment and/or treatment follow-up services Facility type Referral Hospital 81 74 68 81 97 87 84 45 77 2 General Hospital 59 61 52 72 79 81 83 48 61 7 Primary Hospital 41 39 33 51 63 82 94 29 39 3 Health Center 24 32 19 24 31 57 73 19 17 173 Health Post 53 31 24 23 41 90 100 21 2 233 Higher Clinic 70 66 63 76 87 87 60 62 55 11 Medium Clinic 70 75 67 64 82 82 63 49 39 30 Lower Clinic 57 73 57 54 65 92 69 25 19 26 Managing authority Government/ public 41 32 22 24 37 76 89 21 10 413 Other governmental (military, prison, federal police) 100 95 95 91 100 100 18 14 5 1 Private for profit 65 71 62 63 77 85 64 44 35 65 NGO (mission/ faith- based, nonprofit) 56 74 55 54 63 85 91 38 45 5 Region Tigray 47 46 42 52 58 69 82 36 23 22 Afar 38 27 21 34 47 57 70 20 47 3 Amhara 52 37 32 25 41 88 89 16 11 120 Oromia 47 33 23 31 43 79 87 24 6 168 Somali 23 41 17 22 31 59 79 8 23 6 Benishangul Gumuz 4 23 4 21 21 73 85 13 23 3 157 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 SNNP 29 35 20 21 31 68 84 22 13 130 Gambella 37 32 32 45 45 84 92 32 53 1 Harari 42 47 39 63 66 82 74 13 39 2 Addis Ababa 80 80 76 71 94 83 69 60 59 26 Dire Dawa 45 49 42 47 60 96 84 40 36 3 Urban/rural Urban 54 58 44 50 61 81 75 36 38 112 Rural 41 32 23 24 38 77 88 20 6 373 Total 44 38 28 30 43 77 85 24 13 485 Note: The indicator presented in this table comprise country specific standard precautions for client examination for TB within the health facility assessment methodology proposed by Ethiopian SPA+, 2014. 1 Piped water, water in bucket with specially fitted tap, or water in pour pitcher. 2 Non-latex equivalent gloves are acceptable. 3 Waste receptacles with plastic bin liner. 5. Conclusion and Recommendations 5.1 conclusions In view of the above results, the following conclusions are to be drawn. • More than two-third of facilities excluding health posts and (one third of health posts) in Ethiopia offer any TB diagnostic, treatment or/and treatment follow up services. • Less than half of the facilities excluding health posts have the capacity to stain sputum for TB diagnosis. • Of all facilities excluding health posts offering any TB services, treatment and diagnosis guideline is observed to be available in about half of the facilities while about two third of facilities (65 percent in health posts) report that they have at least one provider received in-service training related to Tb services two years prior to the survey. • Among facilities excluding health posts offering any TB diagnostic, treatment, and/or treatment follow up services, two third of them have a system for diagnosing TB clients for HIV. 5.2 Recommendations • The capacity of health facilities to stain sputum smear for TB diagnosis should be capacitated. • Guideline of TB services, treatment and diagnosis should be provided and maintained to a service area. • Early identification of HIV is important for TB patients and adequate infection control measures to minimize the opportunity for cross infection. • Expansion of culture and drug susceptibility testing are necessary for TB patients in Ethiopia. Acknowledgement The 2014 Ethiopia Service Provision Assessment Plus (2014 ESPA+) survey was undertaken by the Ethiopian 158 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2015) Volume 13, No 1, pp 145-159 Public Health Institute (EPHI). Technical support for the survey was provided by World Bank and ICF International under the MEASURE DHS Project. The United States Agency for International Development (USAID), World Bank, UNICEF, Irish Aid, and World Health Organization provided the financial support. Reference [1] Central Statistical Agency [Ethiopia] and ICF International. 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia, and Calverton, Maryland, USA: Central Statistical Agency and ORC Macro. [2] Federal Democratic of Ethiopia, Minister of health. Health Sector Development Plan IV (HSDP IV) 2010/11 - 2014/15; 2010. FMoH, Addis Ababa, Ethiopia. [3] WHO.2011. Global Plan to Stop TB: 2011-2015 [4] FMOH/EHRNI. 2011. First Ethiopian National Population Based Tuberculosis Prevalence Survey: July 2011, Addis Ababa [5] FMOH.2013. Health Sector Development Programme IV Annual Performance Report, 2013. [6] WHO.2011. Global Tuberculosis Control: 2011 WHO report WHO. 2006. The STOP TB strategy. 159 1. Introduction 2. Objective 3. Methodology 3.1 study design and location 3.2 data collection instrument 3.3 Data Collection Approaches 3.4 Sampling 3.5 Training and Data Collection Pre-Test Main Assessment 3.6 Data management and analysis 3.7 Ethical clearance 4. Result 4.1 Availability of tuberculosis diagnosis and management services 4.1.1 Availability of tuberculosis Diagnosis services 4.1.2 Availability of Tuberculosis Management Services 4.2 Readiness to Provide Quality Tuberculosis Services 4.2.1 Availability of guidelines and trained staff for TB Services 4.2.2 Diagnostic capability and availability of medicines for treatment of Tuberculosis 4.2.3 Tuberculosis Infection Control 5. Conclusion and Recommendations Acknowledgement Reference