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Ambade M, Kim R, Subramanian S. Experience of health care utilization for inpatient and outpatient services among older adults in India. PUBLIC HEALTH IN PRACTICE 2024; 8:100541. [PMID: 39309250 PMCID: PMC11413678 DOI: 10.1016/j.puhip.2024.100541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 07/24/2024] [Accepted: 07/26/2024] [Indexed: 09/25/2024] Open
Abstract
Background Patient experiences have not been documented at all India level among older adults for inpatient and outpatient services. We provide all-India and sub national estimates on six domains of patient experience, namely: waiting time, respectful treatment, clarity of explanation provided, privacy during consultation, treated by provider of choice, and cleanliness of facility. Methods Unit records of adults aged 45 years and above for their inpatient (n = 4330) or outpatient (n = 33,724) service use were assessed from the Longitudinal Ageing Survey of India (LASI), conducted in 2017-18. We identified patient experience as negative if the respondent rated it as either "Bad" or "Very Bad" on a five-point Likert scale. We computed proportion of negative experience by socio-economic status, geographic location, and type of healthcare facilities. We used binary logistic regression to estimate predictors of negative patient experience, and a three-level logistic regression model to partition the total geographic variation of patient experiences. Findings Most individuals rated their experience in all six domains as "Good". Negative experiences were higher among patients who used public facilities, specifically for waiting time and cleanliness of facility. Among inpatients, the higher-than-average negative experience was noted in the north and northwest, while among outpatients, it was higher in the northeast. The largest geographic variation in negative patient experience was attributable to the villages/CEBs for all domains in outpatient services and three domains of inpatient services, whereas states accounted for the other three inpatient domains. Interpretation Majority of older adults rated their experience of healthcare use positively, but less for public health facilities.
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Affiliation(s)
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
| | - S.V. Subramanian
- Harvard Center for Population and Development Studies, 9 Bow Street Cambridge, MA, 02138, USA
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Noh DH, Darwar R, Uba BV, Gab-Deedam S, Yani S, Jimoh A, Waziri N, David J, Amoo B, Atobatele S, Dimas J, Fadahunsi R, Sampson S, Simple E, Ugbenyo G, Wisdom M, Asekun A, Pallas SW, Ikwe H. Cost of COVID-19 vaccine delivery in nine States in Nigeria via the U.S. Government Initiative for Global Vaccine Access. BMC Health Serv Res 2024; 24:1232. [PMID: 39402600 PMCID: PMC11472445 DOI: 10.1186/s12913-024-11645-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 09/23/2024] [Indexed: 10/19/2024] Open
Abstract
BACKGROUND In 2022, the U.S. Centers for Disease Control and Prevention collaborated with implementing partners, African Field Epidemiology Network and Sydani Group, to support COVID-19 vaccination efforts in Nigeria. To characterize the costs of COVID-19 vaccination, this study evaluated financial costs per dose for activities implemented to support the intensification campaign for COVID-19 vaccination. METHODS This retrospective evaluation collected secondary data from existing expenditure and programmatic records on resource utilization to roll out COVID-19 vaccination during 2022. The study included incremental financial costs of the activities implemented to support an intensification campaign for COVID-19 vaccination across nine states and six administrative levels in Nigeria from the perspective of the external donor (U.S. Government). Costs for vaccines and injection supplies, transport of vaccines, and any economic costs, including government in-kind contributions, were not included. All costs were converted from Nigerian Naira to 2022 U.S. Dollars (US$). RESULTS The estimated financial delivery cost of the COVID-19 vaccination intensification campaign was US$0.84 per dose (total expenditure of US$6.29 million to administer 7,461,971 doses). Most of the financial resources were used for fieldwork activities (86%), followed by monitoring and supervision activities (8%), coordination activities (5%), and training-related activities (1%). Labor (58%) and travel (37%) were the resource inputs that accounted for the majority of the cost, while shares of other resource inputs were marginal (1% for each). Most labor costs (79%) were spent on payments for mass vaccination campaign teams, including pay-for-performance incentives. By administrative level, the largest share of costs (46%) was for pay-for-performance incentives at the community, health facility, or campus levels combined, followed by local government area level (24%), community level only (15%), state level (9%), national level (3%), campus level only (1%), and health facility level only (< 1%). CONCLUSIONS Findings from the evaluation can help to inform resources needed for vaccination activities to respond to future outbreaks and pandemics in resource-limited settings, particularly to reach new target populations not regularly included in routine childhood immunization delivery.
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Affiliation(s)
- Dave Haeyun Noh
- Global Immunization Division, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Roopa Darwar
- Global Immunization Division, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Belinda V Uba
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | | | - Stella Yani
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | | | | | | | - Babatunde Amoo
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | - Sunday Atobatele
- Sydani Group Nigeria, Abuja, Nigeria
- Sydani Institute for Research and Innovation (SIRI), Abuja, Nigeria
| | - Janada Dimas
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | - Rhoda Fadahunsi
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | - Sidney Sampson
- Sydani Group Nigeria, Abuja, Nigeria
- Sydani Institute for Research and Innovation (SIRI), Abuja, Nigeria
| | - Edwin Simple
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | - Gideon Ugbenyo
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | - Margeret Wisdom
- African Field Epidemiology Network (AFENET) Nigeria, Abuja, Nigeria
| | - Adeyelu Asekun
- Global Immunization Division, Global Health Center, Centers for Disease Control and Prevention, Abuja, Nigeria
| | - Sarah W Pallas
- Global Immunization Division, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hadley Ikwe
- Global Immunization Division, Global Health Center, Centers for Disease Control and Prevention, Abuja, Nigeria
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Das J, Chowdhury A. Improving primary healthcare: An evidence-based approach towards informal providers. Indian J Med Res 2024; 159:385-389. [PMID: 39361803 PMCID: PMC11414783 DOI: 10.25259/ijmr_365_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Indexed: 10/05/2024] Open
Affiliation(s)
- Jishnu Das
- McCourt School of Public Policy and the Walsh School of Foreign Service, Georgetown University, Washington D.C., United States
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Shridhar SV, Beghini F, Alexander M, Singh A, Juárez RM, Brito IL, Christakis NA. Environmental, socioeconomic, and health factors associated with gut microbiome species and strains in isolated Honduras villages. Cell Rep 2024; 43:114442. [PMID: 38968070 PMCID: PMC11290354 DOI: 10.1016/j.celrep.2024.114442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/27/2024] [Accepted: 06/19/2024] [Indexed: 07/07/2024] Open
Abstract
Despite a growing interest in the gut microbiome of non-industrialized countries, data linking deeply sequenced microbiomes from such settings to diverse host phenotypes and situational factors remain uncommon. Using metagenomic data from a community-based cohort of 1,871 people from 19 isolated villages in the Mesoamerican highlands of western Honduras, we report associations between bacterial species and human phenotypes and factors. Among them, socioeconomic factors account for 51.44% of the total associations. Meta-analysis of species-level profiles across several datasets identified several species associated with body mass index, consistent with previous findings. Furthermore, the inclusion of strain-phylogenetic information modifies the overall relationship between the gut microbiome and the phenotypes, especially for some factors like household wealth (e.g., wealthier individuals harbor different strains of Eubacterium rectale). Our analysis suggests a role that gut microbiome surveillance can play in understanding broad features of individual and public health.
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Affiliation(s)
- Shivkumar Vishnempet Shridhar
- Yale Institute for Network Science, Yale University, New Haven, CT, USA; Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Francesco Beghini
- Yale Institute for Network Science, Yale University, New Haven, CT, USA
| | - Marcus Alexander
- Yale Institute for Network Science, Yale University, New Haven, CT, USA
| | - Adarsh Singh
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, USA
| | | | - Ilana L Brito
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, USA.
| | - Nicholas A Christakis
- Yale Institute for Network Science, Yale University, New Haven, CT, USA; Department of Biomedical Engineering, Yale University, New Haven, CT, USA; Department of Statistics and Data Science, Yale University, New Haven, CT, USA; Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
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Daniels B, Yi Chang A, Gatti R, Das J. The medical competence of health care providers in sub-Saharan Africa: Evidence from 16 127 providers across 11 countries. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae066. [PMID: 38855056 PMCID: PMC11157171 DOI: 10.1093/haschl/qxae066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/03/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024]
Abstract
Despite a consensus that quality of care is critically deficient in low-income countries, few nationally representative studies provide comparable measures of quality of care across countries. To address this gap, we used nationally representative data from in-person administrations of clinical vignettes to measure the competence of 16 127 health care providers across 11 sub-Saharan African countries. Rather than large variations across countries, we found that 81% of the variation in competence is within countries and the characteristics of health care providers do not explain most of this variation. Professional qualifications-including cadre and education-are only weakly associated with competence: across our sample, one-third of nurses are more competent than the average doctor in the same country and one-quarter of doctors are less competent than the average nurse. Finally, while younger cohorts do tend to be more competent, perhaps reflecting improvements in medical education, it would take 25 decades of turnover to improve care by 10 percentage points, on average, if we were to rely on such improvements alone. These patterns necessitate a fundamentally different approach to health care human resource management, calling into question typical staffing policies based on qualifications and seniority rather than directly measured quality.
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Affiliation(s)
- Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC 20057, United States
| | - Andres Yi Chang
- Office of the Chief Economist for Human Development, The World Bank, Washington, DC 20433, United States
| | - Roberta Gatti
- Office of the Chief Economist for Middle East and North Africa, The World Bank, Washington, DC 20433, United States
| | - Jishnu Das
- McCourt School of Public Policy and the Walsh School of Foreign Service, Georgetown University, Washington, DC 20057, United States
- Centre for Policy Research, New Delhi 110021, India
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Yang Y, Gong X, Song F, Guo R. Evidence-Do Gap in Quality of Direct-To-Consumer Telemedicine: Cross-Sectional Standardized Patient Study in China. Telemed J E Health 2024; 30:e1126-e1137. [PMID: 38039353 DOI: 10.1089/tmj.2023.0473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Abstract
Background: The evidence-do gap between the availability of clinical guidelines and provider practice is well documented, resulting in low health care quality. With the rapid development of telemedicine worldwide, this study aimed to investigate the evidence-do gap and explore the factors for the evidence versus practice deficits as well as low quality in direct-to-consumer telemedicine. Methods: We adopted the standardized patient approach to evaluate the health worker performance and calculate the evidence-do gap in quality of the consultation process, diagnosis, and treatment in telemedicine based on China's national clinical guidelines. Moreover, we further explored the factors associated with the gap through multiple linear regression and logistic regressions. Results: Validated physician-patient interactions (N = 321) were included. On the one hand, the consultation process and treatment quality are less commendable with the huge evidence-do gap. More than three-quarters of the physicians provided low-quality care, as against standard clinical guidelines. On the other hand, the level I, specialized hospitals, doctor, associate chief physicians, and attending physicians, sponsored by Internet enterprises, more times of provider's responses and words were associated with high-quality processes; More total times of provider's responses, urticaria, and nonoffice hours of the visit were associated with high-quality diagnosis; Sponsored by Internet enterprises, more total words of provider's all responses, and urticaria were associated with high-quality treatment. Conclusions: Our findings have important implications in an era in which to better comprehend the evidence-do gap. Efforts to bridge the evidence-do gap should be focused on the important role of institutions and physicians.
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Affiliation(s)
- Yuting Yang
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
| | - Xue Gong
- Department of Quality and Efficiency, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Faying Song
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
| | - Rui Guo
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
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Wagner Z, Mohanan M, Zutshi R, Mukherji A, Sood N. What drives poor quality of care for child diarrhea? Experimental evidence from India. Science 2024; 383:eadj9986. [PMID: 38330118 DOI: 10.1126/science.adj9986] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/08/2023] [Indexed: 02/10/2024]
Abstract
Most health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades. Using randomized experiments in India, we estimated the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider's financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing, whereas stock-outs and financial incentives explain only 6 and 5%, respectively.
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Affiliation(s)
- Zachary Wagner
- Department of Economics, Sociology and Statistics, RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Rushil Zutshi
- Department of Economics, Sociology and Statistics, RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Arnab Mukherji
- Center for Public Policy, Indian Institute of Management Bangalore, Bangalore, Karnataka, India
| | - Neeraj Sood
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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Biswas D, Asadullah A, Khan SH, Khan ZH, Islam MT, Khan AI, Qadri F, Nelson EJ, Watt MH, Leung DT. Qualitative Assessment of a Smartphone-Based Mobile Health Tool to Guide Diarrhea Management in Bangladesh. Am J Trop Med Hyg 2024; 110:159-164. [PMID: 38081051 PMCID: PMC10793020 DOI: 10.4269/ajtmh.23-0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/24/2023] [Indexed: 01/05/2024] Open
Abstract
Diarrheal diseases are a major cause of morbidity and mortality in children worldwide and a significant contributor to antimicrobial resistance. In the absence of laboratory diagnostics to establish diarrhea etiology, electronic clinical decision support tools can help physicians make informed treatment decisions for children with diarrhea. In Bangladesh, we assessed the feasibility and acceptability of an electronic Diarrhea Etiology Prediction algorithm (DEP tool) embedded into a rehydration calculator, which was designed to help physicians manage children with diarrhea, including decisions on antibiotic use. A team of Bangladeshi anthropologists conducted in-depth interviews with physicians (N = 13) in three public hospitals in Bangladesh about their experience using the tool in the context of a pilot trial. Physicians expressed positive opinions of the DEP tool. Participants perceived the tool to be simple and easy to use, with structured guidance on collecting and entering clinical data from patients. Significant strengths of the tool were as follows: standardization of protocol, efficiency of clinical decision-making, and improved clinical practice. Participants also noted barriers that might restrict the widespread impact of the tool, including physicians' reluctance to use an electronic tool for clinical decision-making, increasing work in overburdened healthcare settings, unavailability of a smartphone, and patients' preferences for antibiotics. We conclude that an electronic clinical decision support tool is a promising method for improving diarrheal management and antibiotic stewardship. Future directions include developing and implementing such a tool for informal healthcare physicians in low-resource settings, where families may first seek care for pediatric diarrhea.
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Affiliation(s)
- Debashish Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Asadullah Asadullah
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sazzad Hossain Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Zahid Hasan Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Taufiqul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ashraful Islam Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Eric J. Nelson
- Departments of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Daniel T. Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah
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Powell-Jackson T, King JJC, Makungu C, Quaife M, Goodman C. Management Practices and Quality of Care: Evidence from the Private Health Care Sector in Tanzania. ECONOMIC JOURNAL (LONDON, ENGLAND) 2024; 134:436-456. [PMID: 38077853 PMCID: PMC10702364 DOI: 10.1093/ej/uead075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/05/2023] [Indexed: 02/12/2024]
Abstract
We measure the adoption of management practices in over 220 private for-profit and non-profit health facilities in 64 districts across Tanzania and link these data to process quality-of-care metrics, assessed using undercover standardised patients and clinical observations. We find that better managed health facilities are more likely to provide correct treatment in accordance with national treatment guidelines, adhere to a checklist of essential questions and examinations, and comply with infection prevention and control practices. Moving from the 10th to the 90th percentile in the management practice score is associated with a 48% increase in correct treatment. We then leverage a large-scale field experiment of an internationally recognised management support intervention in which health facilities are assessed against comprehensive standards, given an individually tailored quality improvement plan and supported through training and mentoring visits. We find zero to small effects on management scores, suggesting that improving management practices in this setting may be challenging.
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Si Y, Chen G, Su M, Zhou Z, Yip W, Chen X. The Impact of Physician-Patient Gender Match on Healthcare Quality: An Experiment in China. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.03.23296202. [PMID: 37873451 PMCID: PMC10592995 DOI: 10.1101/2023.10.03.23296202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Despite growing evidence of gender disparities in healthcare utilization and health outcomes, there is a lack of understanding of what may drive such differences. Designing and implementing an experiment using the standardized patients' approach, we present novel evidence on the impact of physician-patient gender match on healthcare quality in a primary care setting in China. We find that, compared with female physicians treating female patients, the combination of female physicians treating male patients resulted in a 23.0 percentage-point increase in correct diagnosis and a 19.4 percentage-point increase in correct drug prescriptions. Despite these substantial gains in healthcare quality, there was no significant increase in medical costs and time investment. Our analyses suggest that the gains in healthcare quality were mainly attributed to better physician-patient communications, but not the presence of more clinical information. This paper has policy implications in that improving patient centeredness and incentivizing physicians' efforts in consultation (as opposed to treatment) can lead to significant gains in the quality of healthcare with modest costs, while reducing gender differences in care.
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Affiliation(s)
- Yafei Si
- School of Risk & Actuarial Studies, University of New South Wales, Australia
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Australia
| | - Gang Chen
- Centre for Health Economics, Monash Business School, Monash University, Australia
| | - Min Su
- School of Public Administration, Inner Mongolia University, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi’an Jiaotong University, China
| | - Winnie Yip
- Harvard T.H. Chan School of Public Health, Harvard University, USA
| | - Xi Chen
- Department of Health Policy and Management, Yale School of Public Health, USA
- Department of Economics, Yale University, USA
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Shapira G, Clarke-Deelder E, Booto BM, Samaha H, Fritsche GB, Muvudi M, Baabo D, Antwisi D, Ramanana D, Benami S, Fink G. Impacts of performance-based financing on health system performance: evidence from the Democratic Republic of Congo. BMC Med 2023; 21:381. [PMID: 37794389 PMCID: PMC10552286 DOI: 10.1186/s12916-023-03062-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Health systems' weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such programs introduced in LMICs to date. METHODS We used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021-2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers' satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain. RESULTS The PBF program improved the structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01-0.08), technical process quality by 5 ppts (0.03-0.07), and non-technical process by 2 ppts (0-0.04). PBF also increased coverage of priority health services by 3 ppts (0.02-0.04). Improvements were also observed for facility management (9 ppts, 0.04-0.15), service fee policies, and users' satisfaction with service affordability (14 ppts, 0.07-0.20). Service fees and health workers' satisfaction were not affected by the program. CONCLUSIONS The results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals. TRIAL REGISTRATION American Economics Association Trial registry AEARCTR-0002880.
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Affiliation(s)
| | - Emma Clarke-Deelder
- The Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland
| | | | | | | | | | - Dominique Baabo
- Ministry of Public Health, Kinshasa, Democratic Republic of Congo
| | - Delphin Antwisi
- Ministry of Public Health, Kinshasa, Democratic Republic of Congo
| | - Didier Ramanana
- Ministry of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Günther Fink
- The Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland
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Wagner Z, Banerjee S, Mohanan M, Sood N. Does the market reward quality? Evidence from India. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023; 23:467-505. [PMID: 36477343 DOI: 10.1007/s10754-022-09341-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
There are two salient facts about health care in low and middle-income countries; (1) the private sector plays an important role and (2) the care provided is often of poor quality. Despite these facts we know little about what drives quality of care in the private sector and why patients seek care from poor quality providers. We use two field studies in India that provide insight into this issue. First, we use a discrete choice experiment to show that patients strongly value technical quality. Second, we use standardized patients to show that better quality providers are not able to charge higher prices. Instead providers are able to charge higher prices for elements of quality that the patient can observe, which are less important for health outcomes. Future research should explore whether accessible information on technical quality of local providers can shift demand to higher quality providers and improve health outcomes.
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Affiliation(s)
| | | | - Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Neeraj Sood
- Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
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Daka DW, Wordofa MA, Woldie M. Know-do gap for sick child care and drivers of knowledge and practice among health extension workers in four regions of Ethiopia: a cross-sectional study. BMJ Open 2023; 13:e069698. [PMID: 37612100 PMCID: PMC10450039 DOI: 10.1136/bmjopen-2022-069698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 08/15/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE Though efforts were made to expand community-based sick child healthcare in Ethiopia, the quality of care provided remained low. Improving quality of care requires understanding providers' knowledge of appropriate care and their actual execution of tasks. This study examined gap between what health extension workers (HEWs) knew and did during the management of sick children in Ethiopia. DESIGN Facility-based cross-sectional study was conducted. SETTING The study was carried out in 52 districts across 4 regions in Ethiopia. PARTICIPANTS We interviewed 274 HEWs and performed observations of consultations done by 150 HEWs supplemented with facility assessment from December 2018 to February 2019. OUTCOME We compared providers' knowledge and performance in the management of childhood pneumonia and diarrhoea. Know-do gap implies the difference in proportion between knowledge and actual practice of HEWs. Logistic regression was used to identify predictors of knowledge and actual practice. RESULTS Providers' correct knowledge ranged from 27.8% to 76.0% for signs and symptoms of pneumonia, and 32.0% to 84% for dehydration signs. Their actual practices ranged from 15.1% to 47.3% for pneumonia and 27.0% to 42.6% for dehydration. The correct knowledge and actual practices for pneumonia and dehydration management were 88.3% vs 15.6% and 93.9% vs 51.3%, respectively. There was significant know-do gap in assessments (16.7%, p=0.002) and management of childhood conditions (68.5%, p<0.0001). Mentorships were associated with providers' knowledge of clinical management, while medicines availability was associated with their actual management practice. CONCLUSIONS While knowledge and actual practice for assessment and management of pneumonia and dehydration ranged from very low to high, what is more concerning is the huge know-do gap among HEWs. Our findings suggest that knowledge-based training is necessary but not sufficient for ensuring correct assessment and management of sick children by HEWs. Continuous support through mentorships and the supply of commodities are critically needed.
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Affiliation(s)
- Dawit Wolde Daka
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
| | | | - Mirkuzie Woldie
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
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Han D, Clarke-Deelder E, Miller N, Opondo K, Burke T, Oguttu M, McConnell M, Cohen J. Health care provider decision-making and the quality of maternity care: An analysis of postpartum care in Kenyan hospitals. Soc Sci Med 2023; 331:116071. [PMID: 37450989 PMCID: PMC10410252 DOI: 10.1016/j.socscimed.2023.116071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/17/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care.
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Affiliation(s)
- Dan Han
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore; Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology and Public Health, Swiss TPH and University of Basel, Basel, Switzerland
| | - Nora Miller
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Kennedy Opondo
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Kisumu Medical and Education Trust, Kisumu, Kenya
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jessica Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100152. [PMID: 37383564 PMCID: PMC10306035 DOI: 10.1016/j.lansea.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 06/30/2023]
Abstract
Background The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations. Methods This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results. Findings Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21-28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19-26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10-16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing. Interpretation One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Use of standardised patients to assess tuberculosis case management by private pharmacies in Patna, India: A repeat cross-sectional study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001898. [PMID: 37235550 PMCID: PMC10218738 DOI: 10.1371/journal.pgph.0001898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023]
Abstract
As the first point of care for many healthcare seekers, private pharmacies play an important role in tuberculosis (TB) care. However, previous studies in India have showed that private pharmacies commonly dispense symptomatic treatments and broad-spectrum antibiotics over-the-counter (OTC), rather than referring patients for TB testing. Such inappropriate management by pharmacies can delaye TB diagnosis. We assessed medical advice and OTC drug dispensing practices of pharmacists for standardized patients presenting with classic symptoms of pulmonary TB (case 1) and for those with sputum smear positive pulmonary TB (case 2), and examined how practices have changed over time in an urban Indian site. We examined how and whether private pharmacies improved practices for TB in 2019 compared to a baseline study conducted in 2015 in the city of Patna, using the same survey sampling techniques and study staff. The proportion of patient-pharmacist interactions that resulted in correct or ideal management, as well as the proportion of interactions resulting in antibiotic, quinolone, and corticosteroid are presented, with standard errors clustered at the provider level. To assess the difference in case management and the use of drugs across the two cases by round, a difference in difference (DiD) model was employed. A total of 936 SP interactions were completed over both rounds of survey. Our results indicate that across both rounds of data collection, 331 of 936 (35%; 95% CI: 32-38%) of interactions were correctly managed. At baseline, 215 of 500 (43%; 95% CI: 39-47%) of interactions were correctly managed whereas 116 of 436 (27%; 95% CI: 23-31%) were correctly managed in the second round of data collection. Ideal management, where in addition to a referral, patients were not prescribed any potentially harmful medications, was seen in 275 of 936 (29%; 95% CI: 27-32%) of interactions overall, with 194 of 500 (39%; 95% CI: 35-43%) of interactions at baseline and 81 of 436 (19%; 95% CI: 15-22%) in round 2. No private pharmacy dispensed anti-TB medications without a prescription. On average, the difference in correct case management between case 1 vs. case 2 dropped by 20 percent points from baseline to the second round of data collection. Similarly, ideal case management decreased by 26 percentage points between rounds. This is in contrast with the dispensation of medicines, which had the opposite effect between rounds; the difference in dispensation of quinolones between case 1 and case 2 increased by 14 percentage points, as did corticosteroids by 9 percentage points, antibiotics by 25 percentage points and medicines generally by 30 percentage points. Our standardised patient study provides valuable insights into how private pharmacies in an Indian city changed their management of patients with TB symptoms or with confirmed TB over a 5-year period. We saw that overall, private pharmacy performance has weakened over time. However, no OTC dispensation of anti-TB medications occurred in either survey round. As the first point of contact for many care seekers, continued and sustained efforts to engage with Indian private pharmacies should be prioritized.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | | | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jishnu Das
- Georgetown University, Washington, DC, United States of America
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Ontario, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Si Y, Bateman H, Chen S, Hanewald K, Li B, Su M, Zhou Z. Quantifying the financial impact of overuse in primary care in China: A standardised patient study. Soc Sci Med 2023; 320:115670. [PMID: 36669284 DOI: 10.1016/j.socscimed.2023.115670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Overuse of health care is a potential factor in explaining the rapid increase in health care expenditure in many countries; however, it is difficult to measure overuse. This study employed the novel method of using unannounced standardised patients (SPs) to identify overuse, document its patterns and quantify its financial impact on patients in primary care in China. We trained 18 SPs to present consistent cases of two common chronic diseases and recorded 492 physician-patient interactions in 63 public and private primary hospitals in a capital city in western China in 2017 and 2018. Overuse, defined as the provision of unnecessary medical tests and drugs, was identified by a panel of medical experts based on national clinical guidelines. We estimated linear regression models to investigate how hospital, physician and patient characteristics were associated with overuse and to quantify the financial impact of overuse after controlling for a series of fixed effects. We found overuse in 72.15% of the SP visits. The high prevalence of overuse was similar among public and private hospitals, low-competence and high-competence physicians, male and female physicians, junior and senior physicians and male and female patients, but it varied between patients presenting different diseases. Compared to the non-overuse group, overuse significantly increased the total cost by 117.8%, the test cost by 58.8% and the drug cost by 100.3%. The financial impact of overuse was consistent across the aforementioned hospital, physician and patient characteristics. We suggest that the overuse observed in this study is unlikely to be attributable to physician incompetence but rather to the financing framework for primary care in China. These findings illuminate the cost escalation of primary care in China, which is a form of medical inefficiency that should be urgently addressed.
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Affiliation(s)
- Yafei Si
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia.
| | - Hazel Bateman
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Shu Chen
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Katja Hanewald
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Bingqin Li
- Social Policy Research Centre, University of New South Wales, Sydney, Australia
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China.
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18
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King JJC, Powell-Jackson T, Hargreaves J, Makungu C, Goodman C. Does increased provider effort improve quality of care? Evidence from a standardised patient study on correct and unnecessary treatment. BMC Health Serv Res 2023; 23:190. [PMID: 36823637 PMCID: PMC9948477 DOI: 10.1186/s12913-023-09149-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Poor quality of care, including overprovision (unnecessary care) is a global health concern. Greater provider effort has been shown to increase the likelihood of correct treatment, but its relationship with overprovision is less clear. Providers who make more effort may give more treatment overall, both correct and unnecessary, or may have lower rates of overprovision; we test which is true in the Tanzanian private health sector. METHODS Standardised patients visited 227 private-for-profit and faith-based facilities in Tanzania, presenting with symptoms of asthma and TB. They recorded history questions asked and physical examinations carried out by the provider, as well as laboratory tests ordered, treatments prescribed, and fees paid. A measure of provider effort was constructed on the basis of a checklist of recommended history taking questions and physical exams. RESULTS 15% of SPs received the correct care for their condition and 74% received unnecessary care. Increased provider effort was associated with increased likelihood of correct care, and decreased likelihood of giving unnecessary care. Providers who made more effort charged higher fees, through the mechanism of higher consultation fees, rather than increased fees for lab tests and drugs. CONCLUSION Providers who made more effort were more likely to treat patients correctly. A novel finding of this study is that they were also less likely to provide unnecessary care, suggesting it is not simply a case of some providers doing "more of everything", but that those who do more in the consultation give more targeted care.
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Affiliation(s)
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
| | - James Hargreaves
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
| | - Christina Makungu
- Ifakara Health Instiute, Plot 463, Kiko Avenue, P.O. Box 78 373, Mikocheni, Dar es Salaam, Tanzania
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
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Clarke-Deelder E, Opondo K, Oguttu M, Burke T, Cohen JL, McConnell M. Immediate postpartum care in low- and middle-income countries: A gap in healthcare quality research and practice. Am J Obstet Gynecol MFM 2023; 5:100764. [PMID: 36216312 DOI: 10.1016/j.ajogmf.2022.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/16/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
The immediate postpartum period carries significant risks for complications such as postpartum hemorrhage and sepsis. Postpartum monitoring, including taking vital signs and monitoring blood loss, is important for the early identification and management of complications, but many women in low- and middle-income countries receive minimal attention in the period following childbirth to facility discharge. The World Health Organization recently released new guidelines on postnatal care, which include recommendations for immediate postpartum monitoring. In light of the new guidelines, this presented an opportune moment to address the gaps in postpartum monitoring in low- and middle-income countries. In this commentary, we bring attention to the importance of immediate postpartum monitoring. We identified opportunities for strengthening this often overlooked aspect of maternity care through improvements in quality measurement and data availability, research into barriers against high-quality care, and innovations in service delivery design.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland (Dr Clarke-Deelder).
| | - Kennedy Opondo
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke)
| | - Monica Oguttu
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu)
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke); Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (Dr Burke); Harvard Medical School, Boston, MA (Dr Burke)
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
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20
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Sheikh NS, Gele A. Factors influencing the motivation of maternal health workers in conflict setting of Mogadishu, Somalia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001673. [PMID: 36963062 PMCID: PMC10021578 DOI: 10.1371/journal.pgph.0001673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 01/27/2023] [Indexed: 03/26/2023]
Abstract
Motivated health workers play an important role in delivering high-quality maternal health services, especially in low-income countries where maternal mortality rates are high, and shortages of human resource for health is prevalent. The aim of this study is to investigate maternal health workers' motivation in three tertiary hospitals in Mogadishu Somalia. We used a semi-structured questionnaire that was validated and widely used in Sub-Saharan Africa to collect data from 220 health workers across three tertiary hospitals in Mogadishu between February and April 2020. Health worker motivation was measured using seven constructs: general motivation, burnout, job satisfaction, intrinsic job satisfaction, organizational commitment, conscientiousness, timeliness and attendance. A multiple linear regression analysis was performed to determine the predictors of health worker motivation. The results show that male health workers have a higher work motivation, with a mean score of 92.75 (SD 21.31) versus 90.43 (SD 21.61) in women. As regards to profession, significant correlation was found between health workers' motivation and being an assistant (coeff, 6.873, p = 0.001), nurse (coeff, 5.111, p = 0.000), physicians (coeff, 2.898 p = 0.042), pediatric assistants (coeff, 2.878, p = 0.048), midwife (coeff, 3.822, P = 0.01), and others (supervisor and pharmacist) (coeff, 5.623, P = 0.001). Unexpectedly, the gynecologists and midwives were the least motivated groups among the different professions, with mean scores of 83.63, (SD: 27.41) and 86.95 (SD: 21.08), respectively. Of the aforementioned seven motivation constructs, the highest mean motivation scores (from 1-5) were observed in conscientiousness and intrinsic job satisfaction. These results highlight the importance of targeted interventions that increase female health workers' motivation, particularly gynecologists and midwives. This can be done by providing non-financial incentives, in addition to encouraging their participation in the decision-making process. Further research is needed to investigate the effect of a lack of motivation among gynecologists and midwives on maternal health in Somalia.
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Affiliation(s)
- Naima Said Sheikh
- Department of Health Service Research, Norwegian Institute of Public Health, Oslo, Norway
- Institute of Public Health Science, University of Life Sciences, Oslo, Norway
| | - Abdi Gele
- Department of Health Service Research, Norwegian Institute of Public Health, Oslo, Norway
- Department of Health Service Research, Somali Institute for Health Research, Garowe, Somalia
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21
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Leung T, Cai Y, Cao J, He Q, Wang X, Lu Y, Liang H, Xu D, Liao J. The Agreement Between Virtual Patient and Unannounced Standardized Patient Assessments in Evaluating Primary Health Care Quality: Multicenter, Cross-sectional Pilot Study in 7 Provinces of China. J Med Internet Res 2022; 24:e40082. [PMID: 36459416 PMCID: PMC9758641 DOI: 10.2196/40082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/27/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The unannounced standardized patient (USP) is the gold standard for primary health care (PHC) quality assessment but has many restrictions associated with high human and resource costs. Virtual patient (VP) is a valid, low-cost software option for simulating clinical scenarios and is widely used in medical education. It is unclear whether VP can be used to assess the quality of PHC. OBJECTIVE This study aimed to examine the agreement between VP and USP assessments of PHC quality and to identify factors influencing the VP-USP agreement. METHODS Eleven matched VP and USP case designs were developed based on clinical guidelines and were implemented in a convenience sample of urban PHC facilities in the capital cities of the 7 study provinces. A total of 720 USP visits were conducted, during which on-duty PHC providers who met the inclusion criteria were randomly selected by the USPs. The same providers underwent a VP assessment using the same case condition at least a week later. The VP-USP agreement was measured by the concordance correlation coefficient (CCC) for continuity scores and the weighted κ for diagnoses. Multiple linear regression was used to identify factors influencing the VP-USP agreement. RESULTS Only 146 VP scores were matched with the corresponding USP scores. The CCC for medical history was 0.37 (95% CI 0.24-0.49); for physical examination, 0.27 (95% CI 0.12-0.42); for laboratory and imaging tests, -0.03 (95% CI -0.20 to 0.14); and for treatment, 0.22 (95% CI 0.07-0.37). The weighted κ for diagnosis was 0.32 (95% CI 0.13-0.52). The multiple linear regression model indicated that the VP tests were significantly influenced by the different case conditions and the city where the test took place. CONCLUSIONS There was low agreement between VPs and USPs in PHC quality assessment. This may reflect the "know-do" gap. VP test results were also influenced by different case conditions, interactive design, and usability. Modifications to VPs and the reasons for the low VP-USP agreement require further study.
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Affiliation(s)
| | - Yiyuan Cai
- Department of Epidemiology and Medical Statistics, School of Public Health, Guizhou Medical University, Guiyang, China
| | - Jin Cao
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Qianyu He
- Department of Medical Statistics & Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Xiaohui Wang
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Lu
- Department of Preventive Medicine & Maternal and Child Health, School of Public Health, Guizhou Medical University, Guiyang, China
| | - Huijuan Liang
- Research Institute for Health Policy of Inner Mongolia, Inner Mongolia Medical University, Hohhot, China
| | - Dong Xu
- Center for World Health Organization Studies, Department of Health Management, School of Health Management of Southern Medical University, Guangzhou, China.,ACACIA Lab for Implementation Research, Southern Medical University Institute for Global Health, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Jing Liao
- Department of Medical Statistics & Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
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22
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Okeke EN. Playing defense? Health care in the era of Covid. JOURNAL OF HEALTH ECONOMICS 2022; 85:102665. [PMID: 35952443 PMCID: PMC9358334 DOI: 10.1016/j.jhealeco.2022.102665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 06/15/2023]
Abstract
Health workers have to balance their own welfare vs. that of their patients particularly when patients have a readily transmissible disease. These risks become more consequential during an outbreak, and especially so when the chance of severe illness or mortality is non-negligible. One way to reduce risk is by reducing contact with patients. Such changes could be along the intensive or extensive margins. Using data on primary care outpatient encounters during the early months of the Covid-19 pandemic, I document important changes in the intensity of provider-patient interactions. Significantly, I find that adherence to clinical guidelines, the probability that routine procedures such as physical examinations were completed, and even the quality of information given by health providers, all declined sharply. I present evidence that these effects likely reflect risk mitigation behavior by health providers.
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Affiliation(s)
- Edward N Okeke
- Department of Economics, Sociology and Statistics, RAND, 1200 South Hayes, Arlington, VA 22202, United States of America.
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Meng S, Wang Q, Wu Y, Xue H, Li L, Ye R, Chen Y, Pappas L, Akhtar M, Dill SE, Sylvia S, Zhou H, Rozelle S. The know-do gap in quality of health for chronic non-communicable diseases in rural China. Front Public Health 2022; 10:953881. [PMID: 36062129 PMCID: PMC9435052 DOI: 10.3389/fpubh.2022.953881] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/25/2022] [Indexed: 01/24/2023] Open
Abstract
Proper management of non-communicable diseases (NCDs) is a severe challenge to China's rural health system. This study investigates what influences the poor medical treatment of NCDs (diabetes and angina) by evaluating the "know-do gap" between provider knowledge and practice. To determine whether low levels of provider knowledge low quality of patient care is the primary constraint on the quality of NCDs diagnosis and treatment in rural China. Providers from Village Clinics (VC) and Township Health Centers (THC), and Standardized Patients (SP) were selected by a multi-stage random sampling method. Clinical vignettes were administered to 306 providers from 103 VCs and 50 THCs in rural Sichuan Province. SPs presented diabetes symptoms completed 97 interactions with providers in 46 VCs and 51 THCs; SPs presented angina symptoms completed 100 interactions with providers in 50 VCs and 50 THCs. Process quality, diagnosis quality, and treatment quality were assessed against national standards for diabetes and angina. Two-tailed T-tests and tests of proportions for continuous outcomes and tests of proportions for binary dependent variables were used to compare vignette and SP results. Differences between vignette and SP data calculated the know-do gap. Regression analyses were used to examine the providers/facility characteristics and knowledge/practice associations. THC providers demonstrated significantly more knowledge in vignettes and better practices in SP visits than VC providers. However, levels of knowledge were low overall: 48.2% of THC providers and 28.2% of VC providers properly diagnosed type 2 diabetes, while 23.8% of THC providers and 14.7% of VC providers properly diagnosed angina. With SPs, 2.1% of THC providers and 6.8% of VC providers correctly diagnosed type 2 diabetes; 25.5% of THC providers and 12.8% of VC providers correctly diagnosed angina. There were significant know-do gaps in diagnosis process quality, diagnosis quality, and treatment quality for diabetes (p < 0.01), and in diagnosis process quality (p < 0.05) and treatment quality for angina (p < 0.01). Providers in rural China display low levels of knowledge when treating diabetes and angina. Despite low knowledge, evidence of the know-do gap indicates that low-quality healthcare is the primary constraint on the quality of NCD diagnosis and treatment in rural China. Our research findings provide a new perspective for the evaluation of the medical quality and a technical basis for the development of new standardized cases in the future.
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Affiliation(s)
- Sha Meng
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,Department of Operation Management, West China Hospital, Sichuan University, Chengdu, China
| | - Qingzhi Wang
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yuju Wu
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Linhua Li
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Ruixue Ye
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lucy Pappas
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Muizz Akhtar
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sarah-Eve Dill
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Huan Zhou
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Huan Zhou
| | - Scott Rozelle
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
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Clarke-Deelder E, Afriyie DO, Nseluke M, Masiye F, Fink G. Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia. BMC Public Health 2022; 22:1205. [PMID: 35710372 PMCID: PMC9202228 DOI: 10.1186/s12889-022-13549-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/24/2022] [Indexed: 11/15/2022] Open
Abstract
Background In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce. Methods We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals. Results A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies. Conclusions The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13549-3.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Doris Osei Afriyie
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Mweene Nseluke
- Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka, Zambia
| | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Günther Fink
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Saha J, Mondal S, Chouhan P, Hussain M, Yang J, Bibi A. Occurrence of Diarrheal Disease among Under-Five Children and Associated Sociodemographic and Household Environmental Factors: An Investigation Based on National Family Health Survey-4 in Rural India. CHILDREN (BASEL, SWITZERLAND) 2022; 9:658. [PMID: 35626835 PMCID: PMC9139802 DOI: 10.3390/children9050658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 12/07/2022]
Abstract
Diarrheal disease is a significant public health problem leading to mortality and morbidity among children aged 0-59 months in rural India. Therefore, the rationale of this study was to identify the sociodemographic and environmental predictors associated with diarrhea among under-five children in rural India. A total of 188,521 living children (0-59 months) were studied from the National Family Health Survey-4, (NFHS-4) 2015-2016. Bivariate and binary logistic regression models were carried out from the available NFHS-4 data for selected sociodemographic and environmental predictors to identify the relationship of occurrence of diarrhea using STATA 13.1. In rural India, children aged 12-23 months, 24-35 months, 36-47 months, and 48-59 months were significantly improbable to suffer diarrheal disease. Children of the female sex, as well as children of scheduled tribes (ST) and other backward classes (OBC), were less likely to experience diarrhea. The disease was more likely to occur among children of scheduled castes (SC); Muslim or other religions; children belonging to central, eastern, and western regions; children with low birth weight; as well as children with improper stool disposal and rudimentary roof materials. In the rural parts of India, sociodemographic and household environmental factors were most influential. Effective community education; improved handwashing practices; pure water supply; and proper waste disposal, including building and utilizing latrines, would help reduce the burden of diarrheal disease in children.
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Affiliation(s)
- Jay Saha
- Department of Geography, University of Gour Banga (UGB), Malda 732103, WB, India; (S.M.); (P.C.)
| | - Sabbir Mondal
- Department of Geography, University of Gour Banga (UGB), Malda 732103, WB, India; (S.M.); (P.C.)
| | - Pradip Chouhan
- Department of Geography, University of Gour Banga (UGB), Malda 732103, WB, India; (S.M.); (P.C.)
| | - Mulazim Hussain
- The Children Hospital, Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad 44000, Pakistan;
| | - Juan Yang
- Chinese Academy of Science and Technology for Development, Beijing 100038, China
| | - Asma Bibi
- Independent Researcher, Lahore 54000, Pakistan;
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26
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Brenner S, Madhavan S, Nseya CK, Sese C, Fink G, Shapira G. Competent and deficient provision of childbirth services: a descriptive observational study assessing the quality of intrapartum care in two provinces of the Democratic Republic of the Congo. BMC Health Serv Res 2022; 22:551. [PMID: 35468822 PMCID: PMC9040341 DOI: 10.1186/s12913-022-07737-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/25/2022] [Indexed: 11/28/2022] Open
Abstract
Background A majority of women in the Democratic Republic of the Congo (DRC) give birth in a health facility, but maternal and newborn mortality remains high. In rural areas, the quality of facility-based delivery care is often low. This study examines clinical quality of intrapartum care in two provinces of the DRC. Methods We observed process and input elements of delivery care provision at 29 facilities in Kwilu and Kwango provinces. Distinguishing non-performance attributable to provider behavior vs. input constraints, we compared both providers’ adherence to clinical standards (“competent care”) and non-adherence to processes for which required inputs were available (“deficient care”). Results Observing a total of 69 deliveries, care was most competent for partograph use (75% cases) and hemorrhage prevention (73%), but least for postpartum monitoring (4%). Competent care was significantly associated with higher case volumes (p = ·03), skilled birth attendance (p = ·05), and nulliparous women (p = ·02). Care was most deficient for infection prevention (62%) and timely care (49%) and associated with cases observed at hospitals and lower delivery volume. Conclusions Low quality was commonly not a result of missing equipment or supplies but related to providers’ non-adherence to standard protocols. Low case volumes and the absence of skilled attendants seemed to be main factors for sub-standard quality care. Birth assistance during labor stage 2 was the only intrapartum stage heavily affected by the unavailability of essential equipment. Future interventions should strengthen links between birth attendants’ practice to clinical protocols.
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Affiliation(s)
- Stephan Brenner
- Heidelberg Institute of Global Health, University Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
| | - Supriya Madhavan
- Global Financing Facility and The World Bank, Washington, DC, USA
| | - Céline Kanionga Nseya
- Institut Supérieur des Techniques Médicales, Kinshasa, Democratic Republic of the Congo.,Bureau Appui Technique, Division Provinciale de la Santé, Kinshasa, Democratic Republic of the Congo
| | - Claude Sese
- Programme de Développement du Système de Santé (PDSS), Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Gil Shapira
- Development Research Group (DECRG), The World Bank, Washington, DC, USA
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27
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Kwan A, Boone CE, Sulis G, Gertler PJ. Do private providers give patients what they demand, even if it is inappropriate? A randomised study using unannounced standardised patients in Kenya. BMJ Open 2022; 12:e058746. [PMID: 35304401 PMCID: PMC8935168 DOI: 10.1136/bmjopen-2021-058746] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Low and varied quality of care has been demonstrated for childhood illnesses in low-income and middle-income countries. Some quality improvement strategies focus on increasing patient engagement; however, evidence suggests that patients demanding medicines can favour the selection of resistant microbial strains in the individual and the community if drugs are inappropriately used. This study examines the effects on quality of care when patients demand different types of inappropriate medicines. METHODS We conducted an experiment where unannounced standardised patients (SPs), locally recruited individuals trained to simulate a standardised case, present at private clinics. Between 8 March and 28 May 2019, 10 SPs portraying caretakers of a watery diarrhoea childhood case scenario (in absentia) conducted N=200 visits at 200 private, primary care clinics in Kenya. Half of the clinics were randomly assigned to receive an SP demanding amoxicillin (an antibiotic); the other half, an SP demanding albendazole (an antiparasitic drug often used for deworming), with other presenting characteristics the same. We used logistic and linear regression models to assess the effects of demanding these inappropriate medicines on correct and unnecessary case management outcomes. RESULTS Compared with 3% among those who did not demand albendazole, the dispensing rate increased significantly to 34% for those who did (adjusted OR 0.06, 95% CI 0.02 to 0.22, p<0.0001). Providers did not give different levels of amoxicillin between those demanding it and those not demanding it (adjusted OR 1.73, 95% CI 0.51 to 5.82). Neither significantly changed any correct management outcomes, such as treatment or referral elsewhere. CONCLUSION Private providers appear to account for both business-driven benefits and individual health impacts when making prescribing decisions. Additional research is needed on provider knowledge and perceptions of profit and individual and community health trade-offs when making prescription decisions after patients demand different types of inappropriate medicines. TRIAL REGISTRATION NUMBERS American Economic Association Registry (#AEARCTR-0000217) and Pan African Clinical Trial Registry (#PACTR201502000770329).
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Affiliation(s)
- Ada Kwan
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Division of Health Policy and Management, University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Claire E Boone
- Division of Health Policy and Management, University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Giorgia Sulis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Paul J Gertler
- University of California Berkeley Haas School of Business, Berkeley, California, USA
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Liu H, Li H, Teuwen DE, Sylvia S, Shi H, Rozelle S, Yi H. Irrational Use of Medicine in the Treatment of Presumptive Asthma Among Rural Primary Care Providers in Southwestern China. Front Pharmacol 2022; 13:767917. [PMID: 35242030 PMCID: PMC8885990 DOI: 10.3389/fphar.2022.767917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/19/2022] [Indexed: 12/02/2022] Open
Abstract
Poor knowledge, scarce resources, and lack of or misaligned incentives have been widely documented as drivers of the irrational use of medicine (IUM), which significantly challenges the efficiency of health systems across the globe. However, there is limited understanding of the influence of each factor on IUM. We used detailed data on provider treatment of presumptive asthma cases in rural China to assess the contributions of provider knowledge, resource constraints, and provider behavior on IUM. This study enrolled 370 village providers from southwest China. All providers responded to a clinical vignette to test their knowledge of how to treat presumptive asthma. Resource constraints (“capacity”) were defined as the availability of the prescribed medicines in vignette. To measure provider behavior (“performance”), a subset of providers (104 of 370) were randomly selected to receive unannounced visits by standardized patients (SPs) who performed of presumptive asthma symptoms described in the vignette. We found that, 54% (201/370) of providers provided the vignette-based patients with prescriptions. Moreover, 67% (70/104) provided prescriptions for the SPs. For the vignette, only 10% of the providers prescribed the correct medicines; 38% prescribed only unnecessary medicines (and did not provide correct medicine); 65% prescribed antibiotics (although antibiotics were not required); and 55% prescribed polypharmacy prescriptions (that is, they prescribed five or more different types of drugs). For the SP visits, the numbers were 12%, 51%, 63%, and 0%, respectively. The lower number of medicines in the SP visits was due, in part, to the injections’ not being allowed based on ethical considerations (in response to the vignette, however, 65% of providers prescribed injections). The difference between provider knowledge and capacity is insignificant, while a significant large gap exists between provider performance and knowledge/capacity (for 11 of 17 indicators). Our analysis indicated that capacity constraints play a minor role in driving IUM compared to provider performance in the treatment of asthma cases in rural China. If similar findings hold for other disease cases, this suggests that policies to reduce the IUM in rural China have largely been unsuccessful, and alternatives for improving aligning provider incentives with appropriate drug use should be explored.
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Affiliation(s)
- Huidi Liu
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Huibo Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Dirk E Teuwen
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sean Sylvia
- Department of Health Policy and Management and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Haonan Shi
- Business Development Center, Red Cross Society of China, Beijing, China
| | - Scott Rozelle
- Center on China's Economy and Institution, Stanford University, Stanford, CA, United States
| | - Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
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Kovacs R, Lagarde M. Does high workload reduce the quality of healthcare? Evidence from rural Senegal. JOURNAL OF HEALTH ECONOMICS 2022; 82:102600. [PMID: 35196633 PMCID: PMC9023795 DOI: 10.1016/j.jhealeco.2022.102600] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
There is a widely held perception that staff shortages in low and middle-income countries (LMICs) lead to excessive workloads, which in turn worsen the quality of healthcare. Yet there is little evidence supporting these claims. We use data from standardised patient visits in Senegal and determine the effect of workload on the quality of primary care by exploiting quasi-random variation in workload. We find that despite a lack of staff, average levels of workload are low. Even at times when workload is high, there is no evidence that provider effort or quality of care are significantly reduced. Our data indicate that providers operate below their production possibility frontier and have sufficient capacity to attend more patients without compromising quality. This contradicts the prevailing discourse that staff shortages are a key reason for poor quality primary care in LMICs and suggests that the origins likely lie elsewhere.
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Affiliation(s)
- Roxanne Kovacs
- Department of Economics and Centre for Health Governance, University of Gothenburg, Vasagatan 1, Gothenburg, Sweden.
| | - Mylene Lagarde
- London School of Economics and Political Science, Department of Health Policy, Houghton Street, London, UK
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30
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Kovacs RJ, Lagarde M, Cairns J. Can patients improve the quality of care they receive? Experimental evidence from Senegal. WORLD DEVELOPMENT 2022; 150:105740. [PMID: 35115735 PMCID: PMC8651629 DOI: 10.1016/j.worlddev.2021.105740] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 06/14/2023]
Abstract
Providers in many low and middle-income countries (LMICs) often fail to correctly diagnose and treat their patients, even though they have the clinical knowledge to do so. Against the backdrop of many failed attempts to increase provider effort, this study examines whether quality of care can be improved by encouraging patients to be more active during consultations. We design a simple experiment with undercover standardised patients who randomly vary how much information they disclose about their symptoms. We find that providers are 27% more likely to correctly manage a patient who volunteers several key symptoms of their condition at the start of the consultation, compared to a typical patient who shares less information. Lower performance in the control group is not due to providers' lack of knowledge, an incapacity to ask the right questions, or a response to time or resource constraints. Instead, providers' low motivation seems to limit their ability to adapt their effort to patients' inputs in the consultation. Our findings provide proof-of-concept evidence that interventions making patients more active in their consultations could significantly improve the quality of care in LMICs.
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Affiliation(s)
- Roxanne J. Kovacs
- Department of Economics and Centre for Health Governance, University of Gothenburg, Sweden
| | - Mylene Lagarde
- London School of Economics and Political Science, Department of Health Policy, United Kingdom
| | - John Cairns
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, United Kingdom
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31
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Clarke‐Deelder E, Eliakimu E, Mbatia R, Bohren MA, Mashasi I, Larson E. Measuring user experience of care among caregivers of sick children: validation and descriptive analysis in a sample of 75 health facilities in rural Tanzania. Trop Med Int Health 2022; 27:317-329. [DOI: 10.1111/tmi.13730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Emma Clarke‐Deelder
- Department of Epidemiology and Public Health Swiss Tropical and Public Health Institute Basel Switzerland
| | - Eliudi Eliakimu
- Health Quality Assurance Unit Ministry of Health, Community Development Gender, Elderly and Children Dodoma Tanzania
| | | | - Meghan A. Bohren
- Gender and Women’s Health Unit Centre for Health Equity School of Population and Global Health University of Melbourne Melbourne Australia
| | - Irene Mashasi
- Management and Development for Health Dar es Salaam Tanzania
| | - Elysia Larson
- Department of Obstetrics and Gynecology Beth Israel Deaconess Medical Center and Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School Boston USA
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Yip W, Kalita A, Bose B, Cooper J, Haakenstad A, Hsiao W, Woskie L, Reich MR. Comprehensive Assessment of Health System Performance in Odisha, India. Health Syst Reform 2022; 8:2132366. [DOI: 10.1080/23288604.2022.2132366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Winnie Yip
- Professor of the Practice of Global Health Policy & Economics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anuska Kalita
- Visiting Scientist & Specialist-India Health Systems, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bijetri Bose
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jan Cooper
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Annie Haakenstad
- Institute of Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - William Hsiao
- K.T. Li Professor of Economics, Emeritus, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Liana Woskie
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Tufts University School of Arts and Sciences, Boston, MA, USA
| | - Michael R. Reich
- Taro Takemi Professor of International Health Policy, Emeritus, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Sudharsanan N, Wetzel S, Nachtnebel M, Loun C, Phy M, Kol H, Bärnighausen T. Know-do gaps for cardiovascular disease care in Cambodia: Evidence on clinician knowledge and delivery of evidence-based prevention actions. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000862. [PMID: 36962790 PMCID: PMC10022025 DOI: 10.1371/journal.pgph.0000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiovascular diseases (CVD) are the leading cause of death in Cambodia. However, it is unknown whether clinicians in Cambodia provide evidence-based CVD preventive care actions. We address this important gap and provide one of the first assessments of clinical care for CVD prevention in an LMIC context. We determined the proportion of primary care visits by adult patients that resulted in evidence-based CVD preventive care actions, identified which care actions were most frequently missed, and estimated the know-do gap for each clinical action. We used data on 190 direct clinician-patient observations and 337 clinician responses to patient vignettes from 114 public primary care health facilities. Our main outcomes were the proportion of patient consultations and responses to care vignettes where clinicians measured blood pressure, blood glucose, body mass index, and asked questions regarding alcohol, tobacco, physical activity, and diet. There were very large clinical care shortfalls for all CVD care actions. Just 6.4% (95% CI: 3.0%, 13.0%) of patients had their BMI measured, 8.0% (4.6%, 13.6%) their blood pressure measured at least twice, only 4.7% (1.9%, 11.2%) their blood glucose measured. Less than 21% of patients were asked about their physical activity (11.7% [7.0%, 18.9%]), smoking (18.0% [11.8%, 26.5%]), and alcohol-related behaviors (20.2% [13.7%, 28.9%]). We observed the largest know-do gaps for blood glucose and BMI measurements with smaller but important know-do gaps for the other clinical actions. CVD care did not vary across clinician cadre or by years of experience. We find large CVD care delivery gaps in primary-care facilities across Cambodia. Our results suggest that diabetes is being substantially underdiagnosed and that clinicians are losing CVD prevention potential by not identifying individuals who would benefit from behavioral changes. The large overall and know-do gaps suggest that interventions for improving preventive care need to target both clinical knowledge and the bottlenecks between knowledge and care behavior.
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Affiliation(s)
- Nikkil Sudharsanan
- Professorship of Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Sarah Wetzel
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | | | - Chhun Loun
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Maly Phy
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Hero Kol
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
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Han D, Nagpal S, Bauhoff S. The Quality of Primary Care in Cambodia: An Assessment of Knowledge and Effort of Public Sector Maternal and Child Care Providers. Health Syst Reform 2022; 8:2124903. [PMID: 36174665 DOI: 10.1080/23288604.2022.2124903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Improving the quality of primary care is essential for achieving universal health coverage in low- and middle-income countries. This study examined the level and variation in primary care provider knowledge and effort in Cambodia, using cross-sectional data collected in 2014-2015 from public sector health centers in nine provinces. The data included clinical vignettes and direct observations of processes of antenatal care, postnatal care, and well-child visits and covered between 290-495 health centers and 370-847 individual providers for each service and type of data. The results indicate that provider knowledge and observed effort were generally low and varied across health centers and across individual providers. In addition, providers' effort scores were generally lower than their knowledge scores, indicating the presence of a "know-do gap." Although higher provider knowledge was correlated with higher levels of effort during patient encounters, knowledge only explained a limited fraction of the provider-level variation in effort. Due to low baseline performance and the know-do gap, improving provider adherence to clinical guidelines through training and practice standardization alone may have limited impact. Overall, the findings suggest that raising the low quality of care provided by Cambodia's public sector will require multidimensional interventions that involve training, strategies that increase provider motivation, and improved health center management. The authors reported there is no funding associated with the work presented in this article.
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Affiliation(s)
- Dan Han
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore
| | - Somil Nagpal
- Global Practice on Health, Nutrition and Population, Jakarta, Indonesia
| | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
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Moucheraud C, Epstein A, Sarma H, Kim SS, Nguyen PH, Rahman M, Tariquijaman M, Glenn J, Payán DD, Menon P, Bossert TJ. Assessing sustainment of health worker outcomes beyond program end: Evaluation results from an infant and young child feeding intervention in Bangladesh. FRONTIERS IN HEALTH SERVICES 2022; 2:1005986. [PMID: 36925817 PMCID: PMC10012630 DOI: 10.3389/frhs.2022.1005986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023]
Abstract
Introduction Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion. Methods We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline, n = 290), 2014 (endline, n = 511) and 2017 (post-endline, n = 600). Health workers in 10 sub-districts were trained and incentivized to deliver intensified IYCF counseling, and participated in social mobilization activities, while health workers in 10 comparison sub-districts delivered standard counseling activities. Accompanying mass media and policy change activities occurred at the national level. The primary outcome is quality of IYCF service delivery (number of IYCF messages reportedly communicated during counseling); intermediate outcomes are IYCF knowledge, job satisfaction, and job readiness. We also assess the role of hypothesized modifiers of program sustainment, i.e. activities of the program: comprehensiveness of refresher trainings and receipt of financial incentives. Multivariable difference-in-difference linear regression models, including worker characteristic covariates and adjusted for clustering at the survey sampling level, are used to compare differences between groups (intervention vs. comparison areas) and over time (baseline, endline, post-endline). Results At endline, health workers in intervention areas discussed significantly more IYCF topics than those in comparison areas (4.9 vs. 4.0 topics, p < 0.001), but levels decreased and the post-endline gap was no longer significant (4.0 vs. 3.3 topics, p = 0.067). Comprehensive refresher trainings were protective against deterioration in service delivery. Between baseline and endline, the intervention increased health workers' knowledge (3.5-point increase in knowledge scores in intervention areas, vs. 1.5-point increase in comparison areas, p < 0.0001); and this improvement persisted to post-endline, suggesting a sustained program effect on knowledge. Job satisfaction and readiness both saw improvements among workers in intervention areas during the project period (baseline to endline) but regressed to a similar level as comparison areas by post-endline. Discussion Our study showed sustained impact of IYCF interventions on health workers' knowledge, but not job satisfaction or job readiness-and, critically, no sustained program effect on service delivery. Programs of limited duration may seek to assess the status of and invest in protective factors identified in this study (e.g., refresher trainings) to encourage sustained impact of improved service delivery. Studies should also prioritize collecting post-endline data to empirically test and refine concepts of sustainment.
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Affiliation(s)
- Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
| | - Adrienne Epstein
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Haribondhu Sarma
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Sunny S Kim
- International Food Policy Research Institute, Washington, DC, United States
| | - Phuong Hong Nguyen
- International Food Policy Research Institute, Washington, DC, United States
| | - Mahfuzur Rahman
- International Centre for Diarrhoeal Disease Research (ICDDR), Dhaka, Bangladesh
| | - Md Tariquijaman
- International Centre for Diarrhoeal Disease Research (ICDDR), Dhaka, Bangladesh
| | - Jeffrey Glenn
- Department of Public Health, Brigham Young University, Provo, UT, United States
| | - Denise D Payán
- Department of Health, Society, and Behavior, University of California, Irvine, CA, United States
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| | - Thomas J Bossert
- School of Public Health, Harvard University, Boston, MA, United States
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Pineda-Antunez C, Contreras-Loya D, Rodriguez-Atristain A, Opuni M, Bautista-Arredondo S. Characterizing health care provider knowledge: Evidence from HIV services in Kenya, Rwanda, South Africa, and Zambia. PLoS One 2021; 16:e0260571. [PMID: 34855816 PMCID: PMC8638969 DOI: 10.1371/journal.pone.0260571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 11/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Identifying approaches to improve levels of health care provider knowledge in resource-poor settings is critical. We assessed level of provider knowledge for HIV testing and counseling (HTC), prevention of mother-to-child transmission (PMTCT), and voluntary medical male circumcision (VMMC). We also explored the association between HTC, PMTCT, and VMMC provider knowledge and provider and facility characteristics. METHODS We used data collected in 2012 and 2013. Vignettes were administered to physicians, nurses, and counselors in facilities in Kenya (66), Rwanda (67), South Africa (57), and Zambia (58). The analytic sample consisted of providers of HTC (755), PMTCT (709), and VMMC (332). HTC, PMTCT, and VMMC provider knowledge scores were constructed using item response theory (IRT). We used GLM regressions to examine associations between provider knowledge and provider and facility characteristics focusing on average patient load, provider years in position, provider working in another facility, senior staff in facility, program age, proportion of intervention exclusive staff, person-days of training in facility, and management score. We estimated three models: Model 1 estimated standard errors without clustering, Model 2 estimated robust standard errors, and Model 3 estimated standard errors clustering by facility. RESULTS The mean knowledge score was 36 for all three interventions. In Model 1, we found that provider knowledge scores were higher among providers in facilities with senior staff and among providers in facilities with higher proportions of intervention exclusive staff. We also found negative relationships between the outcome and provider years in position, average program age, provider working in another facility, person-days of training, and management score. In Model 3, only the coefficients for provider years in position, average program age, and management score remained statistically significant at conventional levels. CONCLUSIONS HTC, PMTCT, and VMMC provider knowledge was low in Kenya, Rwanda, South Africa, and Zambia. Our study suggests that unobservable organizational factors may facilitate communication, learning, and knowledge. On the one hand, our study shows that the presence of senior staff and staff dedication may enable knowledge acquisition. On the other hand, our study provides a note of caution on the potential knowledge depreciation correlated with the time staff spend in a position and program age.
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Affiliation(s)
- Carlos Pineda-Antunez
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | - David Contreras-Loya
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Alejandra Rodriguez-Atristain
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | | | - Sergio Bautista-Arredondo
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
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Ding H, Chen Y, Yu M, Zhong J, Hu R, Chen X, Wang C, Xie K, Eggleston K. The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China. JOURNAL OF HEALTH ECONOMICS 2021; 80:102539. [PMID: 34740053 DOI: 10.1016/j.jhealeco.2021.102539] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China's efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% lower likelihood of having an inpatient admission, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.
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Affiliation(s)
- Hui Ding
- Department of Economics, Stanford University, 579 Jane Stanford Way, Stanford, CA 94305 USA.
| | | | - Min Yu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Jieming Zhong
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Ruying Hu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Xiangyu Chen
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Chunmei Wang
- Tongxiang Center for Disease Control and Prevention, Tongxiang, China
| | - Kaixu Xie
- Tongxiang Center for Disease Control and Prevention, Tongxiang, China
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Amboko B, Stepniewska K, Malla L, Machini B, Bejon P, Snow RW, Zurovac D. Determinants of improvement trends in health workers' compliance with outpatient malaria case-management guidelines at health facilities with available "test and treat" commodities in Kenya. PLoS One 2021; 16:e0259020. [PMID: 34739519 PMCID: PMC8570506 DOI: 10.1371/journal.pone.0259020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Health workers' compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements. METHODS Data from 11 national, cross-sectional health facility surveys undertaken from 2010-2016 were analysed. Association between 31 determinants and improvement trends in five outpatient compliance outcomes were examined using interactions between each determinant and time in multilevel logistic regression models and reported as an adjusted odds ratio of annual trends (T-aOR). RESULTS Among 9,173 febrile patients seen at 1,208 health facilities and by 1,538 health workers, a higher annual improvement trend in composite "test and treat" performance was associated with malaria endemicity-lake endemic (T-aOR = 1.67 annually; p<0.001) and highland epidemic (T-aOR = 1.35; p<0.001) zones compared to low-risk zone; with facilities stocking rapid diagnostic tests only (T-aOR = 1.49; p<0.001) compared to microscopy only services; with faith-based/non-governmental facilities compared to government-owned (T-aOR = 1.15; p = 0.036); with a daily caseload of >25 febrile patients (T-aOR = 1.46; p = 0.003); and with under-five children compared to older patients (T-aOR = 1.07; p = 0.013). Other factors associated with the improvement trends in the "test and treat" policy components and artemether-lumefantrine administration at the facility included the absence of previous RDT stock-outs, community health workers dispensing drugs, access to malaria case-management and Integrated Management of Childhood Illness (IMCI) guidelines, health workers' gender, correct health workers' knowledge about the targeted malaria treatment policy, and patients' main complaint of fever. The odds of compliance at the baseline were variable for some of the factors. CONCLUSIONS Targeting of low malaria risk areas, low caseload facilities, male and government health workers, continuous availability of RDTs, improving health workers' knowledge about the policy considering age and fever, and dissemination of guidelines might improve compliance with malaria guidelines. For prompt treatment and administration of the first artemether-lumefantrine dose at the facility, task-shifting duties to community health workers can be considered.
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Affiliation(s)
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Lucas Malla
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Robert W. Snow
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Haemmerli M, Powell-Jackson T, Goodman C, Thabrany H, Wiseman V. Poor quality for the poor? A study of inequalities in service readiness and provider knowledge in Indonesian primary health care facilities. Int J Equity Health 2021; 20:239. [PMID: 34736459 PMCID: PMC8567576 DOI: 10.1186/s12939-021-01577-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND For many low and middle-income countries poor quality health care is now responsible for a greater number of deaths than insufficient access to care. This has in turn raised concerns around the distribution of quality of care in LMICs: do the poor have access to lower quality health care compared to the rich? The aim of this study is to investigate the extent of inequalities in the availability of quality health services across the Indonesian health system with a particular focus on differences between care delivered in the public and private sectors. METHODS Using the Indonesian Family Life Survey (wave 5, 2015), 15,877 households in 312 communities were linked with a representative sample of both public and private health facilities available in the same communities. Quality of health facilities was assessed using both a facility service readiness score and a knowledge score constructed using clinical vignettes. Ordinary least squares regression models were used to investigate the determinants of quality in public and private health facilities. RESULTS In both sectors, inequalities in both quality scores existed between major islands. In public facilities, inequalities in readiness scores persisted between rural and urban areas, and to a lesser extent between rich and poor communities. CONCLUSION In order to reach the ambitious stated goal of reaching Universal Health Coverage in Indonesia, priority should be given to redressing current inequalities in the quality of care.
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Affiliation(s)
- Manon Haemmerli
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK.
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK
| | - Hasbullah Thabrany
- Centre for Health Economics and Policy Studies, University of Indonesia, Jakarta, Indonesia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK
- Kirby Institute, University of New South Wales, Sydney, Australia
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Dieci M, Wagner Z, Friedman W, Burgess S, Vandermark J, McCoy SI, Shah M, Dow WH. Measuring Family Planning Provider Bias: A Discrete Choice Experiment among Burkinabé, Pakistani, and Tanzanian Providers. Stud Fam Plann 2021; 52:299-320. [PMID: 34472623 DOI: 10.1111/sifp.12170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The unmet need for modern contraception remains high around the world, particularly for youth. While some of this unmet need is driven by limited health infrastructure and method mix availability, many adolescents who visit family planning providers still do not receive methods that fit their needs. This suggests that providers may be biased against youth and that interventions to change provider behavior could help close this gap. However, it is unclear if this bias is a result of age or other characteristics common among young women such as not being married and not having children. We use a discrete choice experiment in Burkina Faso, Pakistan, and Tanzania to disentangle the effects of age on providers' decisions to provide contraception from the effects of other potential confounding factors. We find that, although young women may experience the most bias, age is not the main driver. Rather, marital status and parity seem to influence provider decisions to offer services or counsel on modern methods. These findings suggest that interventions to reduce provider bias should focus on changing behavior towards unmarried and nulliparous women, regardless of their age.
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Affiliation(s)
- Maria Dieci
- Maria Dieci, Sandra I. McCoy, William H. Dow are at the School of Public Health, University of California, Berkeley, Berkeley, CA, 94704, USA
| | - Zachary Wagner
- Zachary Wagner is at the RAND Corporation, Santa Monica, CA, 90401, USA
| | - Willa Friedman
- Willa Friedman is at the Department of Economics, University of Houston, Houston, TX, 77204, USA
| | - Sarah Burgess
- Sarah Burgess, Jessica Vandermark are at the Camber Collective, San Francisco, CA, 94102, USA
| | - Jessica Vandermark
- Sarah Burgess, Jessica Vandermark are at the Camber Collective, San Francisco, CA, 94102, USA
| | - Sandra I McCoy
- Maria Dieci, Sandra I. McCoy, William H. Dow are at the School of Public Health, University of California, Berkeley, Berkeley, CA, 94704, USA
| | - Manisha Shah
- Manisha Shah is at the Luskin School of Public Affairs, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - William H Dow
- Maria Dieci, Sandra I. McCoy, William H. Dow are at the School of Public Health, University of California, Berkeley, Berkeley, CA, 94704, USA
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Agarwal S, Glenton C, Tamrat T, Henschke N, Maayan N, Fønhus MS, Mehl GL, Lewin S. Decision-support tools via mobile devices to improve quality of care in primary healthcare settings. Cochrane Database Syst Rev 2021; 7:CD012944. [PMID: 34314020 PMCID: PMC8406991 DOI: 10.1002/14651858.cd012944.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ubiquity of mobile devices has made it possible for clinical decision-support systems (CDSS) to become available to healthcare providers on handheld devices at the point-of-care, including in low- and middle-income countries. The use of CDSS by providers can potentially improve adherence to treatment protocols and patient outcomes. However, the evidence on the effect of the use of CDSS on mobile devices needs to be synthesized. This review was carried out to support a World Health Organization (WHO) guideline that aimed to inform investments on the use of decision-support tools on digital devices to strengthen primary healthcare. OBJECTIVES To assess the effects of digital clinical decision-support systems (CDSS) accessible via mobile devices by primary healthcare providers in the context of primary care settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Global Index Medicus, POPLINE, and two trial registries from 1 January 2000 to 9 October 2020. We conducted a grey literature search using mHealthevidence.org and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies. SELECTION CRITERIA Study design: we included randomized trials, including full-text studies, conference abstracts, and unpublished data irrespective of publication status or language of publication. Types of participants: we included studies of all cadres of healthcare providers, including lay health workers and other individuals (administrative, managerial, and supervisory staff) involved in the delivery of primary healthcare services using clinical decision-support tools; and studies of clients or patients receiving care from primary healthcare providers using digital decision-support tools. Types of interventions: we included studies comparing digital CDSS accessible via mobile devices with non-digital CDSS or no intervention, in the context of primary care. CDSS could include clinical protocols, checklists, and other job-aids which supported risk prioritization of patients. Mobile devices included mobile phones of any type (but not analogue landline telephones), as well as tablets, personal digital assistants, and smartphones. We excluded studies where digital CDSS were used on laptops or integrated with electronic medical records or other types of longitudinal tracking of clients. DATA COLLECTION AND ANALYSIS A machine learning classifier that gave each record a probability score of being a randomized trial screened all search results. Two review authors screened titles and abstracts of studies with more than 10% probability of being a randomized trial, and one review author screened those with less than 10% probability of being a randomized trial. We followed standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. We used the GRADE approach to assess the certainty of the evidence for the most important outcomes. MAIN RESULTS Eight randomized trials across varying healthcare contexts in the USA,. India, China, Guatemala, Ghana, and Kenya, met our inclusion criteria. A range of healthcare providers (facility and community-based, formally trained, and lay workers) used digital CDSS. Care was provided for the management of specific conditions such as cardiovascular disease, gastrointestinal risk assessment, and maternal and child health. The certainty of evidence ranged from very low to moderate, and we often downgraded evidence for risk of bias and imprecision. We are uncertain of the effect of this intervention on providers' adherence to recommended practice due to the very low certainty evidence (2 studies, 185 participants). The effect of the intervention on patients' and clients' health behaviours such as smoking and treatment adherence is mixed, with substantial variation across outcomes for similar types of behaviour (2 studies, 2262 participants). The intervention probably makes little or no difference to smoking rates among people at risk of cardiovascular disease but probably increases other types of desired behaviour among patients, such as adherence to treatment. The effect of the intervention on patients'/clients' health status and well-being is also mixed (5 studies, 69,767 participants). It probably makes little or no difference to some types of health outcomes, but we are uncertain about other health outcomes, including maternal and neonatal deaths, due to very low-certainty evidence. The intervention may slightly improve patient or client acceptability and satisfaction (1 study, 187 participants). We found no studies that reported the time between the presentation of an illness and appropriate management, provider acceptability or satisfaction, resource use, or unintended consequences. AUTHORS' CONCLUSIONS We are uncertain about the effectiveness of mobile phone-based decision-support tools on several outcomes, including adherence to recommended practice. None of the studies had a quality of care framework and focused only on specific health areas. We need well-designed research that takes a systems lens to assess these issues.
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Affiliation(s)
- Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Maryland (MD), USA
| | | | - Tigest Tamrat
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | | | | | | | - Garrett L Mehl
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Sullivan S, Solis MT, Burrowes S, Basagoitia A. Can mystery patients evaluate the quality of cervical cancer screenings? A pilot study in Bolivia. Rev Salud Publica (Bogota) 2021. [DOI: 10.15446/rsap.v23n4.92654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective This pilot study assesses the feasibility of using mystery patients to evaluate cervical cancer screenings provided to women in rural Bolivia.
Methods We developed a protocol with local officials and adapted and pre-tested a debriefing tool. Eight mystery patients with existing appointments at four purposively selected rural facilities were recruited and trained. An interviewer debriefed patients after their screenings, and entered responses into a spreadsheet for analysis. Ques- tionnaire response frequencies and missing observations were presented.
Results All patients completed screening and debriefing. On average, 93% of the questions were completed, with non-responses largely due to questions that were irrelevant to the screening venue. Responses revealed problems with confidentiality and dignity, minimal exam explanations or health education, inconsistencies across health facilities in Papanicolaou test availability, and problems in delivering and receiving test results.
Conclusion Our findings suggest that the mystery patient method can be useful in evaluating the quality of cervical cancer screening and the delivery of test results in rural Bolivia.
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DeBaun MR, Lai C, Sanchez M, Chen MJ, Goodnough LH, Chang A, Bishop JA, Gardner MJ. Antibiotic resistance: still a cause of concern? OTA Int 2021; 4:e104(1-4). [PMID: 37609480 PMCID: PMC10441676 DOI: 10.1097/oi9.0000000000000104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
Antibiotic resistance remains a global public health concern with significant patient morbidity and tremendous associated health care costs. Drivers of antibiotic resistance are multifaceted and differ between developing and developed countries. Under evolutionary pressure, microbes acquire antibiotic tolerance through a variety of mechanisms at the cellular level. Patients after orthopaedic trauma are vulnerable to drug-resistant pathogens, particularly after open fractures. Traumatologists practicing appropriate antibiotic prophylaxis and treatment regimens mitigate infection and propagation of antibiotic resistance.
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Affiliation(s)
- Malcolm R DeBaun
- Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA
- Department of Orthopaedic Surgery
| | - Cara Lai
- Stanford University School of Medicine
| | | | | | - L Henry Goodnough
- Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA
- Department of Orthopaedic Surgery
| | - Amy Chang
- Department of Medicine-Infectious Disease, Stanford University School of Medicine, Stanford, CA
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Di Giorgio L, Evans DK, Lindelow M, Nguyen SN, Svensson J, Wane W, Welander Tärneberg A. Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries. BMJ Glob Health 2021; 5:bmjgh-2020-003377. [PMID: 33355259 PMCID: PMC7751199 DOI: 10.1136/bmjgh-2020-003377] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Assess the quality of healthcare across African countries based on health providers' clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage. METHODS With nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme. RESULTS Across all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers' absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively. CONCLUSION Our findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers' absenteeism would only modestly increase the average care readiness that meets minimum quality standards.
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Affiliation(s)
| | | | | | | | - Jakob Svensson
- Institute for International Economic Studies, Stockholm University, Stockholm, Sweden
| | - Waly Wane
- World Bank Côte d'Ivoire Office, Abidjan, Côte d'Ivoire
| | - Anna Welander Tärneberg
- Centre for Economic Demography and Department of Economic History, Lund University School of Economics and Management, Lund, Sweden
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Fichera E, Anselmi L, Gwati G, Brown G, Kovacs R, Borghi J. Can Results-Based Financing improve health outcomes in resource poor settings? Evidence from Zimbabwe. Soc Sci Med 2021; 279:113959. [PMID: 33991792 PMCID: PMC8210646 DOI: 10.1016/j.socscimed.2021.113959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/09/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023]
Abstract
Result Based Financing (RBF) has been implemented in health systems across low and middle-income countries (LMICs), with the objective of improving population health. Most evaluations of RBF schemes have focused on average programme effects for incentivised services. There is limited evidence on the potential effect of RBF on health outcomes, as well as on the heterogeneous effects across socio-economic groups and time periods. This study analyses the effect of Zimbabwe's national RBF scheme on neonatal, infant and under five mortality, using Demographic and Health Survey data from 2005, 2010 and 2015. We use a difference in differences design, which exploits the staggered roll-out of the scheme across 60 districts. We examine average programme effects and perform sub-group analyses to assess differences between socio-economic groups. We find that RBF reduced under-five mortality by two percentage points overall, but that this decrease was only significant for children of mothers with above median wealth (2.7 percentage points) and education (2.1 percentage points). RBF increased institutional delivery by seven percentage points – with a statistically significant effect for poorer socio-economic groups and least educated. We also find that RBF reduced c-section rates by three percentage points. We find no detectable effect of RBF on other incentivised services. When considering programme effects over time, we find that effects were only observed during the second phase of the programme (March 2012) with the exception of c-sections, which only reduced in the longer term. Further research is needed to examine whether these findings can be generalised to other settings. Zimbabwe's national Results Based Financing scheme decreased under-five mortality. Among higher wealth and education groups. RBF increased institutional deliveries in the poorest and least educated groups and reduced the rate of c-section. There were no programme effects on other incentivised services. The RBF programme effects generally appear to be stronger earlier in the implementation process.
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Affiliation(s)
- Eleonora Fichera
- Department of Economics, University of Bath, 2.11 - 3 East, Claverton Down Road, BA2 7AY, Bath, UK.
| | - Laura Anselmi
- Health, Organisation, Policy and Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, UK
| | - Gwati Gwati
- Zimbabwe Ministry of Health and Child Care, Zimbabwe
| | - Garrett Brown
- School of Politics and International Studies, University of Leeds, UK
| | - Roxanne Kovacs
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
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Rao KD, Kaur J, Peters MA, Kumar N, Nanda P. Pandemic response in pluralistic health systems: a cross-sectional study of COVID-19 knowledge and practices among informal and formal primary care providers in Bihar, India. BMJ Open 2021; 11:e047334. [PMID: 33931411 PMCID: PMC8098292 DOI: 10.1136/bmjopen-2020-047334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Responding to pandemics is challenging in pluralistic health systems. This study assesses COVID-19 knowledge and case management of informal providers (IPs), trained practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) and Bachelor of Medicine, Bachelor of Surgery (MBBS) medical doctors providing primary care services in rural Bihar, India. DESIGN This was a cross-sectional study of primary care providers conducted via telephone between 1 and 15 July 2020. SETTING Primary care providers from 224 villages in 34 districts across Bihar, India. PARTICIPANTS 452 IPs, 57 AYUSH practitioners and 38 doctors (including 23 government doctors) were interviewed from a census of 1138 primary care providers used by community members that could be reached by telephone. PRIMARY OUTCOME MEASURES Providers were interviewed using a structured questionnaire with choice-based answers to gather information on (1) change in patient care seeking, (2) source of COVID-19 information, (3) knowledge on COVID-19 spread, symptoms and methods for prevention and (4) clinical management of COVID-19. RESULTS During the early days of the COVID-19 pandemic, 72% of providers reported a decrease in patient visits. Most IPs and other private primary care providers reported receiving no COVID-19 related engagement with government or civil society agencies. For them, the principal source of COVID-19 information was television and newspapers. IPs had reasonably good knowledge of typical COVID-19 symptoms and prevention, and at levels similar to doctors. However, there was low stated compliance among IPs (16%) and qualified primary care providers (15% of MBBS doctors and 12% of AYUSH practitioners) with all WHO recommended management practices for suspect COVID-19 cases. Nearly half of IPs and other providers intended to treat COVID-19 suspects without referral. CONCLUSIONS Poor management practices of COVID-19 suspects by rural primary care providers weakens government pandemic control efforts. Government action of providing information to IPs, as well as engaging them in contact tracing or public health messaging can strengthen pandemic control efforts.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Japneet Kaur
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael A Peters
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Priya Nanda
- Bill and Melinda Gates Foundation India, New Delhi, Delhi, India
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Aujla N, Chen YF, Samarakoon Y, Wilson A, Grolmusová N, Ayorinde A, Hofer TP, Griffiths F, Brown C, Gill P, Mallen C, Sartori J, Lilford RJ. Comparing the use of direct observation, standardized patients and exit interviews in low- and middle-income countries: a systematic review of methods of assessing quality of primary care. Health Policy Plan 2021; 36:341-356. [PMID: 33313845 PMCID: PMC8058951 DOI: 10.1093/heapol/czaa152] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 12/31/2022] Open
Abstract
Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers' clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systematic and narrative reviews on the standardized patient method in March 2020 and expanded it to all methods. Search strategies combined indexed terms and keywords. We searched reference lists of eligible articles and sourced additional references from relevant review articles. Titles and abstracts were independently screened by two reviewers and discrepancies resolved through discussion. Data were iteratively coded according to pre-defined categories and synthesized. We included 12 direct comparison studies and eight systematic and narrative reviews. We found that no method was clearly superior to the others-each has pros and cons and may assess different aspects of quality of care provision by healthcare workers. All methods require careful preparation, though the exact domain of quality assessed and ethics and selection and training of personnel are nuanced and the methods were subject to different biases. The differential strengths suggest that individual methods should be used strategically based on the research question or in combination for comprehensive global assessments of quality.
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Affiliation(s)
- Navneet Aujla
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Yen-Fu Chen
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Yasara Samarakoon
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Anna Wilson
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Natalia Grolmusová
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Abimbola Ayorinde
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Timothy P Hofer
- Department of Medicine, UM Institute for Health Policy and Innovation, Building 16 3rd Floor, North Campus Research Centre, University of Michigan Medical School, Ann Arbor, MI 48109-2800 USA
| | - Frances Griffiths
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Celia Brown
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Paramjit Gill
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Christian Mallen
- Keele School of Medicine, David Wetherall Building, Keele University, Keele, ST5 5BG, UK
| | - Jo Sartori
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Whitaker J, Chirwa L, Munthali B, Dube A, Amoah AS, Leather AJM, Davies J. Development and use of clinical vignettes to assess injury care quality in Northern Malawi. Injury 2021; 52:793-805. [PMID: 33487406 DOI: 10.1016/j.injury.2021.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is known that outcomes after injury care in low-and-middle income countries (LMICs) are poorer than those in high income countries. However, little is known about healthcare provider competency to deliver quality injury care in these settings. We developed and used clinical vignettes to evaluate injury care quality in an LMIC setting. METHOD Four serious injury scenarios, developed from agreed best practice, testing diagnostic and management skills, were piloted with high and low-income setting clinicians. Scenarios were used with primary and referral facility clinicians in Malawi. Participants described their clinical course of action (assessment, diagnostic, treatment and management approaches) for each scenario, registering one point per agreed best practice response. Mean percentage total scores were calculated and univariable and multivariable comparison made across provider groups, facility types, injury care frequency and training level. RESULTS Fourteen Doctors, 51 Clinical Officers, 20 Medical Assistants from 11 facilities participated. Mean percentage total vignette scores varied significantly with clinician provider group (Doctors 63.1% vs Clinical Officers 49.6%, p<0.001, Clinical Officers vs Medical Assistants 39.4% p=0.001). Important care aspects most frequently included or omitted were: following chest injury, 88.2% reported chest drain insertion, 7.1% checked for tracheal deviation; following penetrating abdominal injury and shock, 98.8% secured IV access, 0% mentioned tranexamic acid; following severe head injury, 88.2% proposed CT or neurosurgical transfer, 7.1% ensured normotension; and following isolated open lower leg fracture, 90.1% arranged orthopaedic consultation, 2.4% assessed distal neurological status. CONCLUSION These clinical vignettes proved easy to use and collected rich data. This supports their use for assessing and monitoring clinical care quality in other similar settings.
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Affiliation(s)
- John Whitaker
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Chilumba, Karonga District Malawi
| | - Abena S Amoah
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Chilumba, Karonga District Malawi; Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Centre for Applied Health Research, University of Birmingham, Birmingham, UK; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Extraordinary Professor, Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town
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Sonderegger S, Bennett S, Sriram V, Lalani U, Hariyani S, Roberton T. Visualizing the drivers of an effective health workforce: a detailed, interactive logic model. HUMAN RESOURCES FOR HEALTH 2021; 19:32. [PMID: 33706778 PMCID: PMC7953552 DOI: 10.1186/s12960-021-00570-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/18/2021] [Indexed: 05/06/2023]
Abstract
BACKGROUND A strong health workforce is a key building block of a well-functioning health system. To achieve health systems goals, policymakers need information on what works to improve and sustain health workforce performance. Most frameworks on health workforce planning and policymaking are high-level and conceptual, and do not provide a structure for synthesizing the growing body of empirical literature on the effectiveness of strategies to strengthen human resources for health (HRH). Our aim is to create a detailed, interactive logic model to map HRH evidence and inform policy development and decision-making. METHODS We reviewed existing conceptual frameworks and models on health workforce planning and policymaking. We included frameworks that were: (1) visual, (2) comprehensive (not concentrated on specific outcomes or strategies), and (3) designed to support decision-making. We compared and synthesized the frameworks to develop a detailed logic model and interactive evidence visualization tool. RESULTS Ten frameworks met our inclusion criteria. The resulting logic model, available at hrhvisualizer.org , allows for visualization of high-level linkages as well as a detailed understanding of the factors that affect health workforce outcomes. HRH data and governance systems interact with the context to affect how human resource policies are formulated and implemented. These policies affect HRH processes and strategies that influence health workforce outcomes and contribute to the overarching health systems goals of clinical quality, responsiveness, efficiency, and coverage. Unlike existing conceptual frameworks, this logic model has been operationalized in a highly visual, interactive platform that can be used to map the research informing policies and illuminating their underlying mechanisms. CONCLUSIONS The interactive logic model presented in this paper will allow for comprehensive mapping of literature around effective strategies to strengthen HRH. It can aid researchers in communicating with policymakers about the evidence behind policy questions, thus supporting the translation of evidence to policy.
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Affiliation(s)
- Serena Sonderegger
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Sara Bennett
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Veena Sriram
- University of British Columbia, Vancouver, BC, Canada
| | - Ummekulsoom Lalani
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Shreya Hariyani
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Timothy Roberton
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Rokicki S, Mwesigwa B, Cohen JL. Know-do gaps in obstetric and newborn care quality in Uganda: a cross-sectional study in rural health facilities. Trop Med Int Health 2021; 26:535-545. [PMID: 33529436 DOI: 10.1111/tmi.13557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Variable and inadequate quality of maternity care is a critical factor in persistently high rates of maternal and neonatal mortality in Uganda. We investigated whether provider quality of care deviates from knowledge and the factors associated with these 'know-do gaps' in Ugandan maternity facilities. METHODS Data were collected from 109 providers in 40 facilities. Quality was measured using direct observations of intrapartum care, and scores were based on the percentage of essential care actions provided out of a 20-item validated quality index. Knowledge was measured based on the percentage of items that providers reported knowing to do using vignette surveys. The know-do gap was the difference between knowledge and quality. Multivariable models were used to assess the association between provider- and facility-level characteristics and knowledge, quality and know-do gaps. RESULTS The average quality score was 45%, with quality varying widely within and across providers. The mean knowledge score was 70%, yielding a mean know-do gap of 25%. Know-do gaps were largest for practices related to infection control, vitals monitoring, and prevention of postpartum haemorrhage. The association between quality and knowledge scores was positive but small (P = 0.08), so know-do gaps were largest for providers with the highest knowledge scores. Greater provider training was positively associated with knowledge (P = 0.005) but not with quality (P = 0.60). Having 10 or more years of work experience was associated with higher quality scores (5.3, 95%CI: 0.6 to 10.1), while higher patient volumes were associated with lower quality scores (-2.2, 95%CI: -3.7 to - 0.07). None of the factors of provider motivation, cadre, availability of essential medicines and supplies or facility staffing were associated with quality or know-do gaps. CONCLUSIONS Our results indicate that, in Uganda, gaps between knowledge and quality do not appear to be explained by factors such as lack of motivation, education, training or supplies. Gaps are particularly large for essential practices related to prevention of postpartum haemorrhage, a leading cause of maternal mortality in Uganda and similar settings.
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Affiliation(s)
- Slawa Rokicki
- Department of Health Behavior, Society & Policy, Rutgers School of Public Health, Piscataway, NJ, USA.,Geary Institute for Public Policy, University College Dublin, Dublin, Ireland
| | | | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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