Table 2 Assessment of effectiveness parameters
Effectiveness parameter | Description | Quantitative assessment | Qualitative assessment | Analysis |
|---|---|---|---|---|
Efficacy | An estimate of the ability of anti-TB drugs to cure the disease | - Results from clinical trials | - A biological feature of the drugs | |
Targeting accuracy | How well were the cases identified | - A 10-year trend analysis study in SRS reported average case detection rate (CDR) of 19.1% [18] - Another 10-year trend study in Afar region showed 34% CDR - Calculated CDR of 69.1%, from 2017 WHO Global TB Report [2] | In pastoralist areas 19.1–34.0% of TB cases were detected, while at national level 69.1% of cases were detected | |
Availability | Service meets patient’s needs | - As of 2016, 53% of the available facilities in SRS had TB microscopy and 88% had all first-line anti-TB drugs [35] - A study conducted in Afar region reported 28.7% of participants were dissatisfied with service provision [28] - 84% of health facilities in Ethiopia had all first-line anti-TB drugs [35] | - Shortage of trained staff and intermittent stock outs of drugs and laboratory supplies - Available services are concentrated in major towns | For effectiveness estimation: at national level 84% of the required drugs were available while 53–88% of the required services were available in pastoralist areas. |
Accessibility | Health service delivery sites are accessible to the community without significant physical or social barriers | - Travel distance was too far for 60% of participants [27] - More than 84% of pastoralists in SRS lacked access to TB care [24] - At national level, 9% of the population did not use services because health facilities were too far away | - Lack of transport infrastructure (roads), long travel distances to health facilities | 16–40% of health facilities were accessible to pastoralists, while national level accessibility was reported as 91% |
Affordability | Willingness and ability to pay cost of TB service | - In SRS 8.2% delayed treatment due to lack of money [27] - In Bale zone of Oromia 34.2% of pastoralists delayed treatment due to lack of money [26] - At national level 41% reported inability to pay for the service [30] | - The economic burden of TB was the most important concern for pastoralists in SRS [24] | 65.8–91.8% of pastoralists could afford the cost of the service, while at national level 41% could not afford it |
Adequacy | The TB service organisation meets the community’s expectations | - 9.3% of participants in a pastoralist zone of Oromia region delayed treatment because of long waiting time [26] - Dissatisfaction rate in waiting time (70%) and in open hours (63.6%) was reported in Afar region [28] - 77% of the outpatient health provision was from public health services [23] | - Limited supervision and in-service training of staff, poor staffing quality - Insufficient decentralisation of DOTs and inadequate health infrastructure | 30.0–97.7% of pastoralists were satisfied with the service, while at national 77% of the population utilised public health services |
Acceptability | Provider’s characteristics match those of the community | - 87% of pastoralists in SRS preferred traditional medicine [23] - 31.7% of participants reported their symptoms as self-resolving [27] - Health care seeking at national level was 62% [30] | - Lack of trust in health extension workers - Preference for traditional medicine and other informal health services | 13.0–68.3% of patients felt comfor\ with the conventional service providers. In contrast, at national level 62% sought health care |
Compliance | How well provider initiates correct procedure for intervention- How well health care providers conform to standards of TB treatment | - Despite availability of services, only two of six (33.3%) health facilities studied in Afar region followed strict DOTs during the intensive phase [28] - 44% of Ethiopian health facilities had diagnostic and treatment guidelines | - Absence of professionals during working hours | 33.3% of health facilities in pastoral area followed strict DOTs, while at national level 44% of health facilities followed standard guidelines |
Adherence | How well recipient follows medical advice given | - In SRS 4.2% of patients enrolled for TB treatment defaulted over the period 2003–2012 [18]. Default rate was 2.9% in Afar region [19] | - High default rate due to pastoralist mobility versus stationary health facility | 95.8% of patients adhered to treatment in pastoral settings |