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Table 2 Summary of key health systems enablers and constraints to implementation of TB control in Enugu State, South-eastern Nigeria

From: Through service providers’ eyes: health systems factors affecting implementation of tuberculosis control in Enugu State, South-Eastern Nigeria

Key enablers

Key constraints

Leadership and governance

 Stewardship from state-level NTP

Weak bureaucratic accountability from local health system.

 Programme management support

Low government attention to TB control program

 Regular performance review and coordination

Health financing

 External funding for TB control from donors

Budgeted funds are not released to TB control program at the state level.

Absence of TB in local governments’ budget.

TB supervisors’ motorbikes are not replaced for several years.

Human resources

 Supportive supervision of facility TB focal persons.

 Unwillingness of health workers to work in TB control programme

 Frequent re-deployment of skilled TB service providers

 High number of untrained TB service providers.

 Health workers are owed several months of salaries

Health technology

 Use of dedicated logistics agency for drug distribution.

Logistics agency dumped drugs meant for entire local government in one location.

Drug kits does not meet needs of extrapulmonary TB patients and those weighing more than 70 kg.

Shortage of human immunodeficiency virus (HIV) test kits.

Health information system

 Availability of recording and reporting tools

Change in tools are not matched with training of service providers.

 Adaptation of tools to strategies in TB control.

 Introduction of electronic recording and reporting system

Service delivery

 Availability of functional microscopic centre

Stigma by health workers

 Introduction of GeneXpert

Concern for contracting TB

 Engagement of community volunteers and patent medicine vendors

Lack of incentives to attract health workers

 Reduction in duration of treatment from 8 to 6 months

 Many TB treatment centres lack of TB laboratory

 Poorly functioning GeneXpert.

 Weak patient tracking system

 Withdrawal of incentive for community volunteers and patent medicine vendors.

 Limited number of TB/HIV collaborative sites.