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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 enablersKey constraints
Leadership and governance
 Stewardship from state-level NTPWeak bureaucratic accountability from local health system.
 Programme management supportLow government attention to TB control program
 Regular performance review and coordination
Health financing
 External funding for TB control from donorsBudgeted 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 toolsChange 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 centreStigma by health workers
 Introduction of GeneXpertConcern for contracting TB
 Engagement of community volunteers and patent medicine vendorsLack 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.