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.
Health Policy and Planning (2009) 24 (6) pp. 457-466 [doi:10.1093/heapol/czp030].