Assessment of health system challenges and opportunities for possible integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region, Ethiopia: a qualitative study.
BACKGROUND
The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem in low and middle income countries. However, despite the known synergy between the two disease conditions, services for TB and DM have separately been provided. The objective of this study was to explore health system challenges and opportunities for possible integration of DM and TB services.


METHODS
This was a descriptive qualitative study which was conducted in South-Eastern Amhara Region, Ethiopia. Study participants included health workers (HWs), program managers and other stakeholders involved in TB and DM prevention and control activities. Purposive sampling was applied to select respondents. In order to capture diversity of opinions among participants, maximum variation sampling strategy was applied in the recruitment of study subjects. Data were collected by conducting four focus group discussions and 12 in-depth interviews. Collected data were transcribed verbatim and were thematically analyzed using NVivo 10 software program.


RESULTS
A total of 44 (12 in-depth interviews and 32 focus group discussion) participants were included in the study. The study participants identified a number of health system challenges and opportunities affecting the integration of TB-DM services. The main themes identified were: 1. Unavailability of system for continuity of DM care. 2. Inadequate knowledge and skills of health workers. 3. Frequent stockouts of DM supplies. 4. Patient's inability to pay for DM services. 5. Poor DM data management. 6. Less attention given to DM care. 7. Presence of a well-established TB control program up to the community level. 8. High level of interest and readiness among HWs, program managers and leaders at different levels of the health care delivery system.


CONCLUSIONS
The study provided insights into potential health systems challenges and opportunities that need to be considered in the integration of TB-DM services. Piloting TB and DM integrated services in selected HFs of the study area is needed to assess feasibility for possible full scale integration of services for the two comorbid conditions.
Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway. maykm24@yahoo.com.|Amhara Regional State Health Bureau, Bahir-Dar, Ethiopia. maykm24@yahoo.com.
Mahteme Haile
MH
Workneh
Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
Gunnar Aksel
GA
Bjune
Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.|Amhara Regional State Health Bureau, Bahir-Dar, Ethiopia.|Department of Microbiology, Oslo University Hospital, Oslo, Norway.|Department of Bacteriology and Immunology, Norwegian Institute of Public Health, Oslo, Norway.
Solomon Abebe
SA
Yimer
D000328:Adult; D003266:Continuity of Patient Care; D017281:Cost of Illness; D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000458:organization & administration*; D003920:Diabetes Mellitus / Q000191:economics / Q000517:prevention & control*; D005002:Ethiopia; D005251:Fees, Medical; D017144:Focus Groups; D006291:Health Policy; D006296:Health Services / Q000191:economics / Q000600:supply & distribution*; D006801:Humans; D036301:Qualitative Research; D012423:Rural Health / Q000191:economics / Q000706:statistics & numerical data; D012456:Salaries and Fringe Benefits; D011795:Surveys and Questionnaires; D014376:Tuberculosis / Q000191:economics / Q000517:prevention & control*; D014504:Urban Health / Q000191:economics / Q000706:statistics & numerical data
Amhara Region; Challenge; DOTS; Diabetes mellitus; Ethiopia; Health system; Integration; Opportunity; South-Eastern; Tuberculosis