Health Policy and Planning Advance Access originally published online on August 3, 2009
Health Policy and Planning 2009 24(6):457-466; doi:10.1093/heapol/czp030
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Quality of tuberculosis care and its association with patient adherence to treatment in eight Ethiopian districts
1 Nuffield Centre for International Health and Development, Institute of Health Sciences, University of Leeds, Leeds, UK.
2 Mekelle University Medical College, Mekelle, Ethiopia.
3 Department for Diseases Prevention and Control of Tigray region, Mekelle, Ethiopia.
4 South Bank University, London, UK.
5 University of Nottingham Medical School, Division of Epidemiology and Public Health, School of Community Health Science, Nottingham, UK.
* Corresponding author. Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road Leeds, LS2 9JL, UK. Tel: +44 (0)113 3430833. Fax: +44 (0)113 246 0899. E-mail: M.melese{at}leeds.ac.uk
Background Little is known about the quality of tuberculosis (TB) service delivery in public health facilities in Ethiopia and its association with patients’ non-adherence to TB treatment. This study assessed the organization, management and processes of TB care delivery, and their effects on patients’ adherence to TB treatment.
Methods The quality of TB care was investigated in 44 public health facilities from three perspectives: structure, processes of TB care delivery and patient treatment outcome. Quality of care was determined by adherence to national TB guidelines. On-site observations of TB service delivery and interviews with health providers were conducted to evaluate structural factors. Patients (n = 237) in the health facilities were interviewed prospectively at completion of their treatment to determine the quality of tuberculosis care delivered. Three measures of treatment adherence [treatment interruption (
2 weeks), availability of unused TB drugs and treatment default] were quantified from a review of patient treatment registers and an audit of unused TB drugs at patients’ homes. Effects were identified of poor quality structures and processes of service delivery on these three measures of adherence.
Results TB care providers were untrained in 18 (44%) of 44 facilities and daily outpatient TB care was not given in 13 of 44 (25%). Among the 237 patients, 43% interrupted treatment for 15 days and 30% had at least 1 day's dose of TB drugs unused. Patients tended to interrupt and default from treatment when their care provider had been inadequately supervised by district TB control experts and was incapable of dealing with patients’ minor illnesses. Unavailability of daily TB care in health facilities was associated with missing daily doses.
Conclusion Better training of TB care providers and district supervisory support could be important interventions to improve the quality of care delivery and patient adherence to treatment.
Key Words: Tuberculosis, quality of care, treatment adherence, tuberculosis programme, disease control, public sector
Accepted for publication 5 May 2009.