Community and Health Care Providers Perception on Quality of Private Sector Outpatient Malaria Care in North West Ethiopia: A Qualitative Study

Malaria is one of the most important public health problems in Ethiopia contributing to signicant patient morbidity and mortality. Prompt diagnosis and effective malaria case management-through public, private and community health facilities has been one of the key malaria prevention, control and elimination strategies. The objective of this study was to evaluate perceptions of adult malaria patients and healthcare provider on quality of malaria management at private sector outpatient facilities. An exploratory, descriptive, contextual, qualitative research methodology was conducted with 101 participants (i.e. 33 in-depth interviews and ten Focus Group Discussions with 68 discussants). All interview and Focus Group Discussions were audio recorded, transcribed verbatim and analysed using eight steps of Tesch (1990). During data analysis a single theme, two categories and six sub categories were emerged, namely (1) Perceived quality of malaria management at outpatient facilities; (a) essential resources ; (a1) safe outpatient services; (a2) antimalarial drugs and supplies; (a3) health workers; (b) factors inuencing service utilization ; (b1) Physical accessibility; (b2) “Art of care’’; and (b3) ecient malaria diagnosis and treatment services. Finally, enhancing good governance and stewardship of the public sector to tap the potential of private sector, build the service providers capacity and empowering the community on seeking early medical and safety were recommended.


Background
Malaria is an entirely preventable and treatable parasitic disease [1]. In the last two decades, substantial progress has been made in ghting malaria [2]. According to the latest estimates of World Health Organization (WHO) between the year 2000 and 2015, globally, malaria case incidence was reduced by 41% and malaria associated deaths rate by 62% [3]. However, at the beginning of 2016 still malaria was considered to be endemic in 91 countries and territories, with approximately 212 million cases and 429,000 deaths reported in 2015 alone [3].
In Ethiopia, just like other part of sub-Saharan Africa (SSA), malaria is the major public health problem affecting 75% of the 1.1 million square kilometre land mass and where over 60% of the population live at risk of acquiring the diseases [4], a country of 99 million people in 2015 [5]. In malaria endemic countries, the private health sector is a major provider of treatment for malaria and for non-malaria fever [6].
However, patients' treatment-seeking practices vary between and within countries, but overall, worldwide approximately 40% of patients with suspected malaria seek care in the private sector [7]. Similarly, the fth National Health Account (NHA) conforms close to one fth of malaria patients in Ethiopia received diagnosis and treatment services from the formal private health sector [8] [9].
On one hand, the private health sector has signi cant effect at patient and providers level; have effect on quality of care; encompassing safety, effectiveness and patient experience. They can also work to improve equity of access, making care affordable, and reaching out to marginalized populations. In addition, at the ecos-system level, the private health sector will have impact through training of health workforce; contributing to the retention of health workforce within the country and e cient use of resources [10]. On the other hand, there are substantial concerns about quality and safety of care among some private providers, the equity impact of patients' out-of-pocket payments, and a lack of integration with the public health system some to mentions among the lists [11].
The Ethiopian Health tier system has three levels. This tier system includes: the lowest level being Primary Health Care Unit (PHCU) which consists of one health centre and ve satellite health posts per 15000 -25,000 rural or one health centre for 40,000 urban populations, and primary hospital targeted 60,000-100,000 population. The second higher level is General Hospital targeted 1 to 1.5 million people.
And the third higher level is specialized hospital targeted for 3.5 to 5 million people [12]. The private health sector complements the public health services for shared improved health outcomes with the health sector. Furthermore, according to the Ethiopian national minimum standards [13] a medium private clinic should be led by personnel who achieved educational level either Medical Doctor or Public Health O cer or Bachelor of Science in Nursing. And to run a functional clinic a minimum of four additional health personnel (i.e. 2 diploma nurses and 2 laboratory technicians) should be available in a single facility.
The WHO (2011) and EFMOH (2017) recommends access to universal parasitological diagnosis and prompt treatment with effective antimalarial drugs for con rmed cases through public health facilities, private health facilities and community level [4] [6]. Despite the Ethiopian government and its development partners facilitated the availability of malaria care services free of charge through the public health facilities and community health services. Signi cant number of population sought diagnosis and treatment services within the private health facilities. Quality of services signi cantly affected by the perception of both the healthcare providers and services bene ciaries in terms of clinical decision and compliance with treatments [14]. Therefore, engagement of healthcare providers, and patients or care takers improves access to and demand for affordable standardized public health services. However, the perception of both healthcare providers and adult outpatient bene ciaries towards quality of malaria service had never been explored and described in Ethiopia [15]. Hence this qualitative exploratory descriptive study was conducted by the researchers.
In this cross-sectional an exploratory, descriptive, contextual, qualitative study with thematic analysis was employed to deeper understanding of bene ciaries and healthcare providers perceived quality of outpatient malaria care services in private health facilities [15] [24] located in four districts of West Gojjam Administrative Zone, Amhara Regional State, North West Ethiopia, Setting of the study The Amhara Region, where this study was conducted, is one of the nine administrative regional states and two City Governments of Federal Democratic Republic of Ethiopia. West Gojjam Zone is one of the ten Administrative Zones of Amhara Region. It covers an area of 13669 square kilo meters and the zone is further divided into eighteen Woredas (Districts). Woreda, is an area delineated as the basic unit of planning and political administration at the lower level and further subdivided into the lowest government administrative units known as Kebeles (villages) [25]. Finote Selam Town is the capital of West Gojjam Zone, which is located 385 kms North West of Addis Ababa, and 180kms south of the Amhara Regional Capital City Bahir Dar. Based on the 2007 National Population Census, West Gojjam Zone had a projected population of 2,517,825 million people in the year 2015, and 87% of them were rural residents [26]. According to the routine Health Information System report (July 2013 -June 2014), malaria (104,202/ 743851; 14.04%) is the second among ten top leading causes of morbidity in the zone [27]. Eleven medium clinics are providing malaria diagnosis and treatment service in the study areas. All medium clinics are established as private for pro t organizations, but 6 out of 11 facilities are serving the community through Public Private Partnership (PPP) for malaria care services where partner facilities had access for anti-malaria supplies and received technical support from public health sector.

Population and sample size
The research population for this study was adults of greater than 18 years of age who were outpatient malaria service bene ciaries and healthcare providers working in the targeted eleven medium clinics in Finote Selam, Jabih Tehina, Bure and Womberma districs, West Gojjam Zone, North West Ethiopia.
West Gojjam Zone is selected with purposive sampling for its accessibility to the main road and convenience to researchers. However, Woredas are selected based on high burden of malaria. In the year 2012, the incidence of malaria (Fig 1) in selected four Woredas were ranging from 40 to over 100 per 1000 population/November 2012 [28]. All eleven medium clinics are enrolled in this study. The researcher collected qualitative data from 33 healthcare providers who were working in the outpatient facilities of eleven medium clinics. In addition, the researcher collected data from ten ( ve men and ve women) focus group discussions (FGDs) were facilitated with 68 adult outpatient services bene ciaries who diagnosed and treated for uncomplicated malaria infections. Six to eight patients voluntary consented to participate in this study were identi ed with their permanent address and remind twice to participate with cell phone. Each FGD consists of 6 to 8 discussants.

Data collection
Data were collected through in-depth individual interviews, FGDs; and eld notes. The semi structured indepth interviews were conducted with 33 healthcare providers. In average each in-depth interview lasted 45 to 60 minutes. In addition, the FGDs were facilitated with 68 adult outpatient uncomplicated malaria diagnosed and treated patients. In average each FGD lasted within 1:30 hour. Furthermore, the researcher took handwritten notes through observing patient and health workers interaction; and assesses the outpatient facilities. Those patients who consented to take part in this research and completed their antimalarial treatment prior to the data collection were enrolled in the FGDs. The FGDs were consists of ve males and ve females' groups. The data collection was ceased based on saturation or redundancy of data [29].
Measures For Ensuring Trustworthiness Emlan (1995) cited Lincoln and Guba (1985) four criteria for trustworthiness [30]. The criteria are truth value, applicability, consistency and neutrality [31]. In this research rigors were ascertained through concepts of Lincoln and Guba (1985) extended these criteria to the qualitative paradigm and translated the terms to credibility, transferability, dependability and conformability have been used to describe various aspects of trustworthiness [31] [32]. See the table 1 below for applicability of these criteria in this study. Triangulation of data Data were collected using audio tape recorder, type verbatim transcript, eld hand written notes and observation.
Dense description Detailed description of methodology was presented.

Conformability Triangulation
Triangulation the nding of the researcher and independent research expert was considered.

Ethical considerations
The study was approved by the institution review boards (IRB) of University of South Africa (UNISA) and Amhara Regional State Health Bureau, Research and Technology Transfer Core Process. The supporting letter was obtained from West Gojjam Zone Heath Department, Finote Selam, Jabih Tehina, Bure and Wonberma Woreda Health o ces. Additionally, all participants were informed about the overall purpose of the study, procedures of the study, methods of data collection, bene ts and risk of participation, con dentiality; and their right to withdraw anytime during the in-depth interview and Focus group discussions and estimated time to complete the task. After receiving information all study participants singed voluntarily the on the consent form. To maintain the con dentiality of collected data, anonymity was maintained throughout the research process [33] [34].

Data Anaylsis And Discussion
According to Creswell (2014) in qualitative approach, the researcher analyses the data inductively to build form particular to general theme and interpret the meaning of the data [35]. In this study the data analysis was conducted based on Tesch's (1990) method as cited in Creswell (2014) [35]. The data analysis process followed the eight steps of Tesch, namely: (1) get a sense of the whole through reading all transcript (2) pick one on the top of the pile, the document were read and re-read the data; then ideas were jot down at the margin of each page; (3) after completing the second step for several les, the investigator list topics into columns; and topics will be abbreviate as codes; (4) the researcher take the list, review the data and abbreviated codes were written next to the text; then perform preliminary organize the arrangement to see if new categories and code emerge; (5) select most describing words or category; see the data for internal convergence and external divergence; (6) make nal decision on each categories and alphabetize the codes; (7) assemble the data material belong to each category and perform preliminary analysis; and (8) Furthermore, the raw data were re-coded by experienced qualitative researcher and consensus discussions were arranged on the theme. During data analysis a single theme, two categories and six sub-categories were identi ed.

Biographic Data
The mean age with standard deviation (±SD) of thirty-three health workers who participated in semi structured in-depth interview in this study was 33.4 (± 8.3) years. Their median age was 32 years. And the age range was 35 (58-23) years. A little higher than half (51.51%; n = 17) of the in depth interview participants fall into the age category ranges from 25 to 34 years. The majority 69.69% (n = 23) of the participants were males. With regards to the marital status of the participants, slightly higher than two third (69.69%; n = 23) were married. In addition, the majority of the participants 86.95% (n = 20) achieved diploma level of education i.e. 10 grade completed +3 years college study. The mean service year tenure with standard deviation (± SD) by the participant was 10.3 (± 8.9) years; the median was 8 years; and the range was 36 (37 -1) years. Hence, the majority of the health workers serving in the private health facilities are well experienced in the health systems.
The mean age of 68 focus group discussants with standard deviation (± SD) was 28.6 (± 7.5) years. The median age was 26.5 years. And the range was 39 (59-20) years. Slightly higher than one third 35.3% (n = 24) of the FGD participants were categorized between the age of 18 and 24 years. Close to half 33(48.5%) of the participants were females. Three fourth (75%; n = 51) of the discussants were married. And one third (33.3%; n = 24) of the FGD participants were achieved college diploma (i.e. equivalent education with completed secondary school at 10 th grade + 3 years college study).

Findings
The qualitative data obtained from semi-structured in-depth interview with Health Care providers, FGDs with patients and eld notes identi ed a single theme, two categories and six sub categories.
Perceived quality of outpatient malaria services Perceptions of quality of services by the health workers, patients or caretakers have a signi cant effect on clinical decisions and utilization of available services, respectively [14]. This theme featured the perception of Patients and Health Workers on the quality of private health facilities' in outpatient malaria care services. There are two categories revealed in this theme, namely: (1) Essential Resources and (2) factor in uencing utilization of outpatient services (see Table 2). The perceptions of health workers and customers on outpatient's services have positive and negative behavioural effects on their clinical decisions and patients' compliance with health workers advice, respectively [14]. In this category, the researcher identi ed three sub-categories namely: (1) safe outpatient services; (2) anti-malarial drugs and supplies; and (3) health workers.

Safe outpatient facilities
Early in the history of nursing, Florence Nightingale (1946) advocated for safe care [36]. She also continued teaching nurses in their practice to put the patient in the best possible condition. The Council of the European Union (2009) de ned patient safety as freedom, for a patient from unnecessary harm or potential harm associated with health care [37]. Similarly, The World Health Organization (2010) de ned patient safety as prevention of errors and adverse effects to patients associated with healthcare [16]. The Safety and WHO (2011) program describes in the core element of improving patient's safety, which can be addressed by everyone's: health professionals, managers, cleaners and catering staff, administrators, consumers and politicians [6].
In this study, the majorities of health workers perceived that the private sector's outpatient malaria care services facilities were safe for patients or/and care takers. In addition, the health workers perceived the quality of outpatient care for malaria patients in the private medium clinics in terms of better facilities with regards to water supply, electric power supply and experiences of healthcare providers. The following verbatim clearly explains the health workers perceptions regarding safe and comfortable waiting areas: In addition, the focus group discussants perceived private outpatient malaria facilities to be nice and small health facilities that have a few well-labelled rooms that enable patients to easily walk in order to get safe outpatient malaria services. The following verbatim statement was articulated by one of treated adult malaria patient who utilized private sector outpatient services: On the other hand, a few health workers and some malaria outpatient's services bene ciaries stated their safety concern and a higher risk of acquiring diseases through the private facilities poor quality outpatient malaria services. One of female focus group discussant had this to say her safety concerns: "The majorities of the auxiliary staff, who work in the private clinic, are not able to be employed within the public health sector, and they may not pass the national exam prepared by the centre of excellence." [FGD5: Participant F (1)] In-depth interview participants elaborated on their safety concerns in relation to facilities for service provi by saying: Health workers from HF8 and HF10 perceived shortage and lack of quality assured laboratory supplies a icts the quality of outpatient malaria services: "There is a shortage of laboratory supplies; I couldn't get absolute methanol which is useful to x thin blood lm. Therefore, I use to work with less reliable methods to report accurate malaria parasite species and quantify using thick blood lm. This is not in agreement with the recommendations of the National External Quality Assurance (EQA) guidelines, which states thick lm for screening for the presence of the parasite in blood and the thin lm to identify species and quantify the parasite load." [In-depth Interview: HF8, HW2] On the other hand, malaria treated patients clearly depicted that availability of various antimalarial drugs and laboratory services attract them to regularly visit private clinics. Deressa and Ali (2009) who reported that availability of better-quality diagnosis, essential drugs and other supplies are the major factors for patients to visit the private health facilities [39] [40].

Health workers
The presence of quali ed, motivated and competent human resource is essential to provide standard health services for patients [41][42][43] [44]. In this study the majority of the health workers and patients' perceived high quality of outpatient malaria services in line with the availability of experienced and competent health workers in the targeted health facilities. Some of the health workers reported that they are committed to hiring experienced health workers to exceed beyond the expectation of their customers.
One of the health workers from HF2 had to say: "Our patients expect high-quality services from us; we always prepared ourselves to exceed their expectations… we used to hire experienced health workers." [In-depth Interview: HF2, HW1] In addition, malaria treated patients explained their perceptions based their most recent visits to the private health facilities as health workers were working hard to meet their expectation. The following statements showed the experiences of adult malaria patients: However, some of the FGD discussants reported as they were received low-quality healthcare services by junior and non-experienced health workers.
"…in private health facilities, we used to visit for be examined by highly experienced health workers, mostly owners or managers of the health facility. However, there are junior and non-experienced health workers within the team.." Similarly, one of the FGD1 discussants had to say: "…the health worker took blood sample from my ngertips but she didn't give me at least clean cotton to hold on the bleeding site…" [FGD1, Participant F(1)]

Factors in uencing utilization of outpatient services
Patient's perception of quality of outpatient care has a direct in uence on consumer's selection of their health providers. Studies con rmed that perceived and actual quality of care has a direct effect on health outcomes [39] [45]. In this study, most patients elicited their positive perception on the outpatient malaria care services they received from private health facilities. However, some patients reported their concern on the availability of effective drugs and competent health providers. The researcher presented the three sub-categories, namely: (1) physical accessibility; (2) "Art of care''; and (3) e cient malaria diagnosis and treatment services.

Physical accessibility
According to Kelley and Hurst (2006) accessibility is de ned as the ease with which health services are reached [46]. They also added that access can be explained by physical, nancial or psychological factors, and requires that health services are a priori available. Jimam, David, Galam, Joseph, and Buoye (2015) identify distance from the health facility as one of the barriers for a community member to seek malaria care services [47]. In this study, the majority health workers reported that their service quality in terms of convenience in opening hours, located within a short distance for the community, and offered with affordable cost for the general public. The following statements were forwarded by the health workers: In addition, two FGD discussants elaborated that accessibility of services were not deterred by a distance of health facility from their home: According to WHO (2006b), an e cient health service is the one which strived to maximizes resource use and avoids waste [44]. The most e cient and gold standard malaria diagnostic method is malaria microscopy [52]. In addition, treating malaria patients with quality assured drugs reduce the cost of medical services and a waste of resources [53]. In this study, the researcher found that health workers used to diagnose and treat patients through ine cient ways. The result shows that most febrile patients were investigated with less sensitive and speci c antibody test, malaria diagnosis with only thick lm and patients with negative results were treated for malaria; and treating uncomplicated malaria cases were treated with three or more antimalarial and other drugs. Therefore, the malaria outpatient services are ine cient. Three individual in-depth interview respondents from HF2, HF3 and HF7 had to say: Our patient wants over treatment; we are not e cient in using limited resources. We used to prescribe antimalarial drugs, with vitamins, dextrose, antibiotics etc…" [In-

Conclusions
This qualitative exploratory and descriptive study was conducted in West Gojjam Zone of Amhara Region, North West Ethiopia. The result of the study suggests that both adult malaria outpatient service bene ciaries and health providers had positive perceptions on the availability of good quality of services. However, there are area of improvements in terms of ensuring safety of patient and healthcare providers, interruption of antimalarial drugs and supplies, poor quality of laboratory reagents, and ine cient management of malaria patients.

RECOMMENDATIONS
Based on the result of this study, the following recommendations are made to improve the quality of outpatient malaria service through private sector: (1) Enhancing good governance and stewardship of the public sector to exploit the potentials and capacities of the private sector through exercising wellfunctioning collaborative public private partnership; (2) Providing tailored capacity building to private health sector providers through case management trainings, coaching and mentorship; (3) Empowering the community to seek medical care and the necessary biosafety using targeted Social and Behavioural . In addition, a support letter from the West Gojjam Zone Health Department was received. Written consent to conduct in-depth individual interview and focus group discussions were taken from all participants of the study. To maintain the con dentiality of collected data, anonymity was maintained throughout the research process.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.