Development of strategies to strengthen tuberculosis diagnostic system in Oromia Region, Ethiopia

Abstract

Background: Tuberculosis (TB) remains a significant public health challenge in Ethiopia, particularly in the Oromia Region, where diagnostic system gaps contribute to missed cases and delayed treatment. The diagnostic policy emphasizes prompt identification, yet implementation barriers persist. Objective: This study aimed to evaluate physical access to TB diagnostics, assess utilisation patterns and determinants, examine diagnostic information use for decision-making, and develop evidence-based strategies to strengthen the TB diagnostic system in Oromia Region, Ethiopia. Methods: A quantitative, cross-sectional descriptive design was employed across the Oromia Region of Ethiopia, encompassing a study population of 171 health facilities and 222 professionals. Using stratified random sampling, a total of 112 health facilities (comprising 31 hospitals, 42 health centres, and 39 public-private mix facilities) alongside 59 managing health organisations were selected. Data collection took place from December 2023 to August 2024, utilizing 2 instruments: (1) structured checklists for retrospective review of tuberculosis diagnostic records (2018–2023); (2) questionnaires administered to 222 health professionals (78% male, 22% female), including laboratory technicians, TB focal persons, and program managers; and geospatial analysis based on the Global Moran’s I statistic to evaluate physical accessibility within radii of <5 km, 5–10 km, and >10 km. Data were analyzed using SPSS version 29 (descriptive statistics and multivariate logistic regression) and Microsoft Excel. To validate and refine strategic priorities, a modified three-round Delphi technique was conducted with 11 national and regional TB experts (radiologists, Histopathologists, national TB program officers, and reference laboratory managers), with a consensus threshold of >70% for item inclusion. Results: Basic laboratory amenities averaged only 58% availability. Only 18.5% of health professionals demonstrated knowledge of national TB guidelines. Conventional microscopy was available in 84% of facilities, but WHO-recommended rapid diagnostics (GeneXpert) reached only 24.1%, with significant urban-rural disparities. Geospatial analysis revealed that 41-50% of populations lacked access within 10km of AFB microscopy, Xpert MTB, and X-ray services. Test utilisation remained below 11% among symptomatic patients, associated with supply shortages (71% of respondents), equipment failures (68%), and inadequate screening practices (OR=0.358, p=0.216). Pulmonary TB case detection averaged 64%, and 27.6% of facilities lacked diagnostic service plans. The Delphi process yielded consensus on five strategic objectives with 30 specific strategies, including: establishing district-level molecular diagnostic centres (90.9% consensus), implementing multi-tiered buffer stock systems (100% consensus), mandating healthcare worker competency training (100% consensus), developing unified diagnostic M&E frameworks with digital dashboards (90.9% consensus), and establishing dedicated coordination bodies from ministry to district level (81.8-100% consensus). Conclusion: The TB diagnostic system in Oromia Region faces critical gaps in infrastructure, health worker knowledge, diagnostic utilisation, and monitoring systems. The developed 30-strategy framework provides an evidence-based, expert-validated roadmap to strengthen confirmatory and supportive TB diagnostics through tiered service delivery, supply chain resilience, workforce capacity building, and data-driven governance.