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A pessimistic view of the impact of armed conflicts on the control of infectious diseases has generated great interest in the role of conflicts on the global TB epidemic. Nowhere in the world is such interest more palpable than in the Horn of Africa Region, comprising Ethiopia, Somalia, Eritrea, Djibouti, Kenya and Sudan. An expanding literature has demonstrated that armed conflicts stall disease control programs through distraction of health system, interruption of patients' ability to seek health care, and the diversion of economic resources to military ends rather than health needs. Nonetheless, until very recently, no research has been done to address the impact of armed conflict on TB epidemics in the Somali Regional State (SRS) of Ethiopia. Methods This study is based on the cross-sectional data collected in 2007, utilizing structured questionnaires filled-out by a sample of 226 TB patients in the SRS of Ethiopia. Data was obtained on the delay patients experienced in receiving a diagnosis of TB, on the biomedical knowledge of TB that patients had, and the level of self-treatment by patients. The outcome variables in this study are the delay in the diagnosis of TB experienced by patients, and extent of self-treatment utilized by patients. Our main explanatory variable was place of residence, which was dichotomized as being in 'conflict zones' and in 'non-conflict zones'. Demographic data was collected for statistical control. Chi-square and Mann-Whitney tests were used on calculations of group differences. Logistic regression analysis was used to determine the association between outcome and predictor variables. Results Two hundred and twenty six TB patients were interviewed. The median delay in the diagnosis of TB was 120 days and 60 days for patients from conflict zones and from non-conflict zones, respectively. Moreover, 74% of the patients residing in conflict zones undertook self-treatment prior to their diagnosis. The corresponding proportion from non-conflict zones was 45%. Fully adjusted logistic regression analysis shows that patients from conflict zones had significantly greater odds of delay (OR = 3.06; 95% CI: 1.47-6.36) and higher self treatment utilization (OR = 3.34; 95% CI: 1.56-7.12) compared to those from non-conflict zones. Conclusion Patients from conflict zones have a longer delay in receiving a diagnosis of TB and have higher levels of self treatment utilization. This suggests that access to TB care should be improved by the expansion of user friendly directly observed therapy short-course (DOTS) in the conflict zones of the region.

A pessimistic view of the impact of armed conflicts on the control of infectious diseases has generated great interest in the role of conflicts on the global TB epidemic. Nowhere in the world is such interest more palpable than in the Horn of Africa Region, comprising Ethiopia, Somalia, Eritrea, Djibouti, Kenya and Sudan. An expanding literature has demonstrated that armed conflicts stall disease control programs through distraction of health system, interruption of patients' ability to seek health care, and the diversion of economic resources to military ends rather than health needs. Nonetheless, until very recently, no research has been done to address the impact of armed conflict on TB epidemics in the Somali Regional State (SRS) of Ethiopia. ; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract Background Delayed diagnosis and treatment of tuberculosis (TB) results in severe disease and a higher mortality. It also leads to an increased period of infectivity in the community. The objective of this study was to determine the length of delays, and analyze the factors affecting the delay from onset of symptoms of pulmonary tuberculosis (PTB) until the commencement of treatment. Methods In randomly selected TB management units (TBMUs), i.e. government health institutions which have diagnosing and treatment facilities for TB in Amhara Region, we conducted a cross sectional study from September 1-December 31/2003. Delay was analyzed from two perspectives, 1. Period between onset of TB symptoms to first visit to any health provider (health seeking period), and from the first health provider visit to initiation of treatment (health providers' delay), and 2. Period between onset of TB symptoms to first visit to a medical provider (patients' delay), and from this visit to commencement of anti-TB treatment (health systems' delay). Patients were interviewed on the same date of diagnosis using a semi-structured questionnaire. Logistics regression analysis was applied to analyze the risk factors of delays. Results A total of 384 new smear positive PTB patients participated in the study. The median total delay was 80 days. The median health-seeking period and health providers' delays were 15 and 61 days, respectively. Conversely, the median patients' and health systems' delays were 30 and 21 days, respectively. Taking medical providers as a reference point, we found that forty eight percent of the subjects delayed for more than one month. Patients' delays were strongly associated with first visit to non-formal health providers and self treatment (P < 0.0001). Prior attendance to a health post/clinic was associated with increased health systems' delay (p < 0.0001). Conclusion Delay in the diagnosis and treatment of PTB is unacceptably high in Amhara region. Health providers' and health systems' delays represent the major portion of the total delay. Accessing a simple and rapid diagnostic test for TB at the lowest level of health care facility and encouraging a dialogue among all health providers are imperative interventions.

Background Delayed diagnosis and treatment of tuberculosis (TB) results in severe disease and a higher mortality. It also leads to an increased period of infectivity in the community. The objective of this study was to determine the length of delays, and analyze the factors affecting the delay from onset of symptoms of pulmonary tuberculosis (PTB) until the commencement of treatment. Methods In randomly selected TB management units (TBMUs), i.e. government health institutions which have diagnosing and treatment facilities for TB in Amhara Region, we conducted a cross sectional study from September 1-December 31/2003. Delay was analyzed from two perspectives, 1. Period between onset of TB symptoms to first visit to any health provider (health seeking period), and from the first health provider visit to initiation of treatment (health providers' delay), and 2. Period between onset of TB symptoms to first visit to a medical provider (patients' delay), and from this visit to commencement of anti-TB treatment (health systems' delay). Patients were interviewed on the same date of diagnosis using a semi-structured questionnaire. Logistics regression analysis was applied to analyze the risk factors of delays. Results A total of 384 new smear positive PTB patients participated in the study. The median total delay was 80 days. The median health-seeking period and health providers' delays were 15 and 61 days, respectively. Conversely, the median patients' and health systems' delays were 30 and 21 days, respectively. Taking medical providers as a reference point, we found that forty eight percent of the subjects delayed for more than one month. Patients' delays were strongly associated with first visit to non-formal health providers and self treatment (P < 0.0001). Prior attendance to a health post/clinic was associated with increased health systems' delay (p < 0.0001). Conclusion Delay in the diagnosis and treatment of PTB is unacceptably high in Amhara region. Health providers' and health systems' delays represent the major portion of the total delay. Accessing a simple and rapid diagnostic test for TB at the lowest level of health care facility and encouraging a dialogue among all health providers are imperative interventions.

Background: The health system of Sudan has experienced several forms of decentralization, as well as, a radical reform. Authority and governance of secondary and tertiary health facilities have been shifted from federal to state levels. Moreover, the provision of health care services have been moved from large federal tertiary level hospitals such as Khartoum Teaching Hospital (KTH) and Jafaar Ibnoaf Hospital (JIH), located in the center of Khartoum, to smaller district secondary hospitals like Ibrahim Malik (IBMH), which is located in the southern part of Khartoum. Exploring stakeholders' perceptions on this decentralisation implementation and its relevant consequences is vital in building an empirical benchmark for the improvement of health systems. Methods: This study utilised a qualitative design which is comprised of in-depth interviews and qualitative content analysis with an inductive approach. The study was conducted between July and December 2015, and aimed at understanding the personal experiences and perceptions of stakeholders towards decentralisation enforcement and the implications on public health services, with a particular focus on the Khartoum locality. It involved community members residing in the Khartoum Locality, specifically in catchments area where hospital decentralisation was implemented, as well as, affiliated health workers and policymakers. Results: The major finding suggested that privatisation of health services occurred after decentralisation. The study participants also highlighted that scrutiny and reduction of budgets allocated to health services led to an instantaneous enforcement of cost recovery user fee. Devolving KTH Khartoum Teaching and Jafar Ibnoaf Hospitals into peripherals with less. Capacity, was considered to be a plan to weaken public health services and outsource services to private sector. Another theme that was highlighted in hospitals included the profit-making aspect of the governmental sector in the form of drug supplying and profit-making retail. Conclusions: A change in health services after the enforcement of decentralisation was illustrated. Moreover, the incapacitation of public health systems and empowerment of the privatisation concept was the prevailing perception among stakeholders. Having contextualised in-depth studies and policy analysis in line with the global liberalisation and adjustment programmes is crucial for any health sector reform in Sudan. ; publishedVersion

Background Engaging all health care providers in tuberculosis (TB) control has been incorporated as an essential component of World Health Organization's Stop TB Strategy and the Stop TB Partnership's global plan 2006-2015. Ethiopia has a growing private health sector. The objective of the present study was to investigate the role of private practitioners (PPs) in TB case detection and assess their perspectives on TB treatment delay in Amhara Region, Ethiopia. Results A cross-sectional study among 112 PPs selected from private health facilities (PHF) in the region was conducted. The study was carried out between May and August 2008 and data was collected using a semi-structured questionnaire. Group differences were analyzed using one-way Anova test and a p-value of < 0.05 was considered statistically significant. In this study, PPs saw a median of 12 TB suspects and 1.5 patients a week. The mean number of TB suspects and patients seen varied significantly among the different professions with p < 0.009 and p < 0.004, respectively. Pulmonary TB patients referred by PPs were delayed up to one week before starting treatment at government health facilities. A 22% increase in the detection of smear-positive TB cases may be achieved by involving all PHFs in the TB control program in the region. Nineteen percent of the PPs indicated that TB patients' prior attendance to non medical health providers resulted in complication of disease and increased treatment delay for TB. Conclusion PPs manage a substantial number of TB suspects and patients in Amhara Region, Ethiopia. The GHF delay observed among TB patients referred by PPs to GHF is unnecessary. Expanding PPM-DOTS in the region and improving the quality of TB care at both government and private health facilities reduces treatment delay and increases TB case detection.

Abstract Background Engaging all health care providers in tuberculosis (TB) control has been incorporated as an essential component of World Health Organization's Stop TB Strategy and the Stop TB Partnership's global plan 2006-2015. Ethiopia has a growing private health sector. The objective of the present study was to investigate the role of private practitioners (PPs) in TB case detection and assess their perspectives on TB treatment delay in Amhara Region, Ethiopia. Results A cross-sectional study among 112 PPs selected from private health facilities (PHF) in the region was conducted. The study was carried out between May and August 2008 and data was collected using a semi-structured questionnaire. Group differences were analyzed using one-way Anova test and a p-value of < 0.05 was considered statistically significant. In this study, PPs saw a median of 12 TB suspects and 1.5 patients a week. The mean number of TB suspects and patients seen varied significantly among the different professions with p < 0.009 and p < 0.004, respectively. Pulmonary TB patients referred by PPs were delayed up to one week before starting treatment at government health facilities. A 22% increase in the detection of smear-positive TB cases may be achieved by involving all PHFs in the TB control program in the region. Nineteen percent of the PPs indicated that TB patients' prior attendance to non medical health providers resulted in complication of disease and increased treatment delay for TB. Conclusion PPs manage a substantial number of TB suspects and patients in Amhara Region, Ethiopia. The GHF delay observed among TB patients referred by PPs to GHF is unnecessary. Expanding PPM-DOTS in the region and improving the quality of TB care at both government and private health facilities reduces treatment delay and increases TB case detection.

Abstract Background Early diagnosis and immediate initiation of treatment are essential for an effective tuberculosis (TB) control program. Delay in diagnosis is significant to both disease prognosis at the individual level and transmission within the community. Most transmissions occur between the onset of cough and initiation of treatment. Methods A systematic review of 58 studies addressing delay in diagnosis and treatment of TB was performed. We found different definitions of, for example, debut of symptoms, first appropriate health care provider, time to diagnosis, and start of treatment. Rather than excluding studies that failed to meet strict scientific criteria (like in a meta-analysis), we tried to extract the "solid findings" from all of them to arrive on a more global understanding of diagnostic delay in TB. Results The main factors associated with diagnostic delay included human immunodeficiency virus; coexistence of chronic cough and/or other lung diseases; negative sputum smear; extrapulmonary TB; rural residence; low access (geographical or sociopsychological barriers); initial visitation of a government low-level healthcare facility, private practitioner, or traditional healer; old age; poverty; female sex; alcoholism and substance abuse; history of immigration; low educational level; low awareness of TB; incomprehensive beliefs; self-treatment; and stigma. Conclusion The core problem in delay of diagnosis and treatment seemed to be a vicious cycle of repeated visits at the same healthcare level, resulting in nonspecific antibiotic treatment and failure to access specialized TB services. Once generation of a specific diagnosis was in reach, TB treatment was initiated within a reasonable period of time.

Background Early diagnosis and immediate initiation of treatment are essential for an effective tuberculosis (TB) control program. Delay in diagnosis is significant to both disease prognosis at the individual level and transmission within the community. Most transmissions occur between the onset of cough and initiation of treatment. Methods A systematic review of 58 studies addressing delay in diagnosis and treatment of TB was performed. We found different definitions of, for example, debut of symptoms, first appropriate health care provider, time to diagnosis, and start of treatment. Rather than excluding studies that failed to meet strict scientific criteria (like in a meta-analysis), we tried to extract the "solid findings" from all of them to arrive on a more global understanding of diagnostic delay in TB. Results The main factors associated with diagnostic delay included human immunodeficiency virus; coexistence of chronic cough and/or other lung diseases; negative sputum smear; extrapulmonary TB; rural residence; low access (geographical or sociopsychological barriers); initial visitation of a government low-level healthcare facility, private practitioner, or traditional healer; old age; poverty; female sex; alcoholism and substance abuse; history of immigration; low educational level; low awareness of TB; incomprehensive beliefs; self-treatment; and stigma. Conclusion The core problem in delay of diagnosis and treatment seemed to be a vicious cycle of repeated visits at the same healthcare level, resulting in nonspecific antibiotic treatment and failure to access specialized TB services. Once generation of a specific diagnosis was in reach, TB treatment was initiated within a reasonable period of time.

Background The health system of Sudan has experienced several forms of decentralization, as well as, a radical reform. Authority and governance of secondary and tertiary health facilities have been shifted from federal to state levels. Moreover, the provision of health care services have been moved from large federal tertiary level hospitals such as Khartoum Teaching Hospital (KTH) and Jafaar Ibnoaf Hospital (JIH), located in the center of Khartoum, to smaller district secondary hospitals like Ibrahim Malik (IBMH), which is located in the southern part of Khartoum. Exploring stakeholders' perceptions on this decentralisation implementation and its relevant consequences is vital in building an empirical benchmark for the improvement of health systems. Methods This study utilised a qualitative design which is comprised of in-depth interviews and qualitative content analysis with an inductive approach. The study was conducted between July and December 2015, and aimed at understanding the personal experiences and perceptions of stakeholders towards decentralisation enforcement and the implications on public health services, with a particular focus on the Khartoum locality. It involved community members residing in the Khartoum Locality, specifically in catchments area where hospital decentralisation was implemented, as well as, affiliated health workers and policymakers. Results The major finding suggested that privatisation of health services occurred after decentralisation. The study participants also highlighted that scrutiny and reduction of budgets allocated to health services led to an instantaneous enforcement of cost recovery user fee. Devolving KTH Khartoum Teaching and Jafar Ibnoaf Hospitals into peripherals with less. Capacity, was considered to be a plan to weaken public health services and outsource services to private sector. Another theme that was highlighted in hospitals included the profit-making aspect of the governmental sector in the form of drug supplying and profit-making retail. Conclusions A change in health services after the enforcement of decentralisation was illustrated. Moreover, the incapacitation of public health systems and empowerment of the privatisation concept was the prevailing perception among stakeholders. Having contextualised in-depth studies and policy analysis in line with the global liberalisation and adjustment programmes is crucial for any health sector reform in Sudan.

Background Despite Malawi government's policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care. Objective The study explores the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care. Methods A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using a semi- structured interview guide that collected information on women's perception on perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. The women were asked how they perceived the care they received from health workers before, during, and after delivery. Data were manually analyzed using thematic analysis. Results Onset of labor at night, rainy season, rapid labor, socio-cultural factors and health workers' attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbors. Two women delivered alone. Most women went to the health facility the same day after delivery. Conclusions This study reveals beliefs about labor and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. Even though, it is not easy to change cultural beliefs to convince women to use health facilities for deliveries. There is a need for further exploration of barriers that prevent women from accessing health care for better understanding and subsequently identification of optimal solutions with involvement of the communities themselves.

BACKGROUND: The health system of Sudan has experienced several forms of decentralization, as well as, a radical reform. Authority and governance of secondary and tertiary health facilities have been shifted from federal to state levels. Moreover, the provision of health care services have been moved from large federal tertiary level hospitals such as Khartoum Teaching Hospital (KTH) and Jafaar Ibnoaf Hospital (JIH), located in the center of Khartoum, to smaller district secondary hospitals like Ibrahim Malik (IBMH), which is located in the southern part of Khartoum. Exploring stakeholders' perceptions on this decentralisation implementation and its relevant consequences is vital in building an empirical benchmark for the improvement of health systems. METHODS: This study utilised a qualitative design which is comprised of in-depth interviews and qualitative content analysis with an inductive approach. The study was conducted between July and December 2015, and aimed at understanding the personal experiences and perceptions of stakeholders towards decentralisation enforcement and the implications on public health services, with a particular focus on the Khartoum locality. It involved community members residing in the Khartoum Locality, specifically in catchments area where hospital decentralisation was implemented, as well as, affiliated health workers and policymakers. RESULTS: The major finding suggested that privatisation of health services occurred after decentralisation. The study participants also highlighted that scrutiny and reduction of budgets allocated to health services led to an instantaneous enforcement of cost recovery user fee. Devolving KTH Khartoum Teaching and Jafar Ibnoaf Hospitals into peripherals with less. Capacity, was considered to be a plan to weaken public health services and outsource services to private sector. Another theme that was highlighted in hospitals included the profit-making aspect of the governmental sector in the form of drug supplying and profit-making retail. ...