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Endehabtu BF, Gelaye KA, Mengiste SA, Tilahun B. Mapping the Role of Digital Health Interventions to Enhance Effective Coverage of Antenatal Care: A Scoping Review. J Multidiscip Healthc 2024; 17:71-82. [PMID: 38196936 PMCID: PMC10775799 DOI: 10.2147/jmdh.s438097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/22/2023] [Indexed: 01/11/2024] Open
Abstract
Background Antenatal care (ANC) is a core component of maternal health services. However, only half of the pregnant women in LMICs obtain WHO recommended minimum of four antenatal contacts. In addition, ANC 4+ is a commonly used indicator in monitoring ANC utilization. However, contact coverage alone provides no indications of service quality. In recent years, digital health interventions bring opportunities to provide quality maternal health care. Yet, there are few reviews on how digital health interventions contribute to improving effective coverage of antenatal care. A rigorous review that examines the role of digital health interventions in improving effective coverage of antenatal care is needed to examine how digital health solutions were rapidly deployed to support quality antenatal care service delivery. Objective This review aimed to map evidence on the role of digital health solutions on quality of antenatal care service to enhance effective ANC coverage. Methods A scoping review approach was used and four Databases (PubMed, Cochrane Library, Scopus and Embase) as well as search engines like Advanced Google Search and Google Scholar were searched from September 1 to 8, 2022. Thematic content analysis was used to present the findings. Results A total of 1701 articles were searched. A total of 27 full-text studies were included in the final analysis. The most reported use of digital health was for client education and behavior change communication. Most studies showed that digital health interventions have proven effective in improving antenatal care. However, most of the studies did not address to assess the quality of ANC services. Conclusion In this review, we found out that digital health solutions targeted at pregnant women can improve antenatal care services. There is body of evidence showing the effectiveness of digital health interventions on a range of maternal health outcomes. Few pieces of literature exist on the use of digital health interventions on the quality of antenatal care services. There is a need for more trial and program evaluation studies that examine the role of digital health interventions on the quality of ANC.
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Affiliation(s)
- Berhanu Fikadie Endehabtu
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Center for Digital Health and Implementation Science, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu Gelaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Binyam Tilahun
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Center for Digital Health and Implementation Science, University of Gondar, Gondar, Ethiopia
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Du J, Huang F, Tang Z. Effect of nutritional intervention in child health care on improving growth and development and disease prevention of infants. Pak J Med Sci 2024; 40:477-481. [PMID: 38356799 PMCID: PMC10862417 DOI: 10.12669/pjms.40.3.7720] [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: 02/17/2023] [Revised: 05/11/2023] [Accepted: 10/19/2023] [Indexed: 02/16/2024] Open
Abstract
Objective To explore the outcome of nutritional intervention in child health care on infant growth and disease prevention. Methods It was a retrospective study. Ninty-two infants who received child health intervention in The Affiliated Hospital of Southwest Medical University from September 2020 to June 2022 were selected as the research objects. According to the random number table method, they were divided into control group (46 cases, routine health intervention) and observation group (46 cases, nutritional intervention based on the control group) using the sealed envelope system. The growth and development, nutritional diseases and guardian satisfaction of the two groups were compared. Results The scores of the observation group were higher than those of the control group in gross motor, fine motor, language and individual-social aspects. The total incidence of nutritional diseases in the observation group (2.17%) was lower than that in the control group (17.39%); In terms of total satisfaction rate, the observation group (100.00%) was higher than the control group (86.96%), with a statistical difference (P<0.05). Conclusion Applying nutrition intervention to child health care plays an important role in maintaining the healthy growth and development of infants and reducing the incidence of nutritional diseases such as anemia and rickets. It needs to be promoted in clinical practice.
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Affiliation(s)
- Juan Du
- Juan Du, Department of Pediatrics, The Affiliated Hospital of Southwest, Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou 646000, Sichuan, China
| | - Feiyan Huang
- Feiyan Huang, Department of Pediatrics, The Affiliated Hospital of Southwest, Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou 646000, Sichuan, China
| | - Zhanghua Tang
- Zhanghua Tang, Department of Pediatrics, The Affiliated Hospital of Southwest, Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou 646000, Sichuan, China
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Yego NKK, Nkurunziza J, Kasozi J. Predicting health insurance uptake in Kenya using Random Forest: An analysis of socio-economic and demographic factors. PLoS One 2023; 18:e0294166. [PMID: 38032867 PMCID: PMC10688734 DOI: 10.1371/journal.pone.0294166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
Universal Health Coverage (UHC) is a global objective aimed at providing equitable access to essential and cost-effective healthcare services, irrespective of individuals' financial circumstances. Despite efforts to promote UHC through health insurance programs, the uptake in Kenya remains low. This study aimed to explore the factors influencing health insurance uptake and offer insights for effective policy development and outreach programs. The study utilized machine learning techniques on data from the 2021 FinAccess Survey. Among the models examined, the Random Forest model demonstrated the highest performance with notable metrics, including a high Kappa score of 0.9273, Recall score of 0.9640, F1 score of 0.9636, and Accuracy of 0.9636. The study identified several crucial predictors of health insurance uptake, ranked in ascending order of importance by the optimal model, including poverty vulnerability, social security usage, income, education, and marital status. The results suggest that affordability is a significant barrier to health insurance uptake. The study highlights the need to address affordability challenges and implement targeted interventions to improve health insurance uptake in Kenya, thereby advancing progress towards achieving Universal Health Coverage (UHC) and ensuring universal access to quality healthcare services.
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Affiliation(s)
- Nelson Kimeli Kemboi Yego
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- Department of Mathematics and Computer Science, Moi University, Kenya
| | - Joseph Nkurunziza
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- School of Economics, University of Rwanda, Kigali, Rwanda
| | - Juma Kasozi
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- Department of Mathematics, Makerere University, Kampala, Uganda
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Asefa A, Gebremedhin S, Marthias T, Nababan H, Christou A, Semaan A, Banke-Thomas A, Tabana H, Al-beity FMA, Dossou JP, Gutema K, Delvaux T, Birabwa C, Dennis M, Grovogui FM, McPake B, Beňová L. Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries. Int J Equity Health 2023; 22:203. [PMID: 37784140 PMCID: PMC10544383 DOI: 10.1186/s12939-023-02015-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.
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Affiliation(s)
- Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Tiara Marthias
- School of Population and Global Health, Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Herfina Nababan
- Institut für Public Health und Pflegeforschung, Universität Bremen, Bremen, Germany
| | - Aliki Christou
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aline Semaan
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Fadhlun M. Alwy Al-beity
- Department of Obstetrcis/Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine Et en Démographie, Cotonou, Bénin
| | - Keneni Gutema
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Fassou Mathias Grovogui
- Centre National de Formation Et de Recherche en Santé Rurale (CNFRSR), Maferinyah, Forécariah Guinea
| | - Barbara McPake
- School of Population and Global Health, Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Allorant A, Fullman N, Leslie HH, Sarr M, Gueye D, Eliakimu E, Wakefield J, Dieleman JL, Pigott D, Puttkammer N, Reiner RC. A small area model to assess temporal trends and sub-national disparities in healthcare quality. Nat Commun 2023; 14:4555. [PMID: 37507373 PMCID: PMC10382513 DOI: 10.1038/s41467-023-40234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Monitoring subnational healthcare quality is important for identifying and addressing geographic inequities. Yet, health facility surveys are rarely powered to support the generation of estimates at more local levels. With this study, we propose an analytical approach for estimating both temporal and subnational patterns of healthcare quality indicators from health facility survey data. This method uses random effects to account for differences between survey instruments; space-time processes to leverage correlations in space and time; and covariates to incorporate auxiliary information. We applied this method for three countries in which at least four health facility surveys had been conducted since 1999 - Kenya, Senegal, and Tanzania - and estimated measures of sick-child care quality per WHO Service Availability and Readiness Assessment (SARA) guidelines at programmatic subnational level, between 1999 and 2020. Model performance metrics indicated good out-of-sample predictive validity, illustrating the potential utility of geospatial statistical models for health facility data. This method offers a way to jointly estimate indicators of healthcare quality over space and time, which could then provide insights to decision-makers and health service program managers.
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Affiliation(s)
- Adrien Allorant
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | - Nancy Fullman
- Department of Global Health, University of Washington, Seattle, WA, USA
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Hannah H Leslie
- Division of Prevention Science, University of California San Francisco, San Francisco, CA, USA
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formation, Dakar, Senegal
| | - Daouda Gueye
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formation, Dakar, Senegal
| | - Eliudi Eliakimu
- Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania
| | - Jon Wakefield
- Department of Statistics and Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joseph L Dieleman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - David Pigott
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Nancy Puttkammer
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, WA, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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G C S, Adhikari N. Decomposing inequality in Maternal and Child Health (MCH) services in Nepal. BMC Public Health 2023; 23:995. [PMID: 37248553 DOI: 10.1186/s12889-023-15906-2] [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: 12/08/2022] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND About 75.5% of women in Nepal's urban areas receive at least four ANC visits, compared to 61.7% of women in the country's rural areas. Similarly, just 34% of women in the lowest wealth quintile give birth in a medical facility compared to 90% of women in the richest group. As a result of this inequality, the poor in emerging nations suffer since those who are better off can make greater use of the healthcare than those who are less fortunate. This study aims to examine and decompose the contributions of various socioeconomic factors towards MCH service inequality in Nepal in the years 2011 and 2016. METHODS Inequality in MCH services was estimated using concentration curves and their corresponding indices using data from Nepal Demographic Health Survey (NDHS) 2011 and 2016. We examined the inequality across three MCH service outcomes: less than 4 ANC visits, no postnatal checkups within 2 months of delivery and no SBA delivery and decomposed them across observed characteristics of the mothers aged between 15 and 49. Furthermore, Oaxaca-blinder decomposition approach was used to measure and decompose the inequality differential between two time periods. RESULTS Inequality in MCH services was prevalent for all 3 MCH outcomes in 2011 and 2016, respectively. However, the concentration indices for <4 ANC visits, no SBA delivery, and no postnatal checkups within 2 months of birth increased from -0.2184, -0.1643, and -0.1284 to -0.1871, -0.0504, and -0.0218 correspondingly, showing the decrease in MCH services inequality over two time periods. Wealth index, women's literacy, place of living, mother's employment status, and problem of distance to reach nearest health facility were the main contributors. CONCLUSION We find that MCH services are clearly biased towards the women with higher living standards. National policies should focus on empowering women through education and employment, along with the creation of health facilities and improved educational institutions, in order to address inequalities in living standards, women's education levels, and the problem of distance. Leveraging these factors can reduce inequality in MCH services.
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Affiliation(s)
- Shreezal G C
- Central Department of Economics, Tribhuvan University, Kirtipur, 44600, Kathmandu, Nepal.
| | - Naveen Adhikari
- Central Department of Economics, Tribhuvan University, Kirtipur, 44600, Kathmandu, Nepal
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Ramadan M, Gutierrez JC, Feil C, Bolongaita S, Bernal O, Villar Uribe M. Capacity and quality of maternal and child health services delivery at the subnational primary healthcare level in relation to intermediate health outputs: a cross-sectional study of 12 low-income and middle-income countries. BMJ Open 2023; 13:e065223. [PMID: 36720573 PMCID: PMC9890757 DOI: 10.1136/bmjopen-2022-065223] [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] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To examine the capacity and quality of maternal and child health (MCH) services at the subnational primary healthcare (PHC) level in 12 low-income and middle-income countries (LMICs) and its association with intermediate health outputs such as coverage and access to care. DESIGN Observational cross-sectional study using matched subnational data from service provision assessment surveys and demographic health surveys from 2007 to 2019. SETTINGS 138 subnational areas with available survey data in 12 LMICs (Afghanistan, Bangladesh, Democratic Republic of Congo, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania and Uganda). OUTCOMES Eight intermediate MCH outcomes/outputs were explored: (1) met need for family planning by modern methods; (2) attendance of four or more antenatal care visits; (3) perceived financial barriers to care; (4) perceived geographical barriers to care; (5) diphtheria-pertussis-tetanus (DPT) third dose coverage; (6) DPT dropout-rate; (7) care-seeking for pneumonia; and (8) oral rehydration solutions coverage. RESULTS Overall, moderate-to-poor PHC performance was observed across the 12 countries, with substantial heterogeneity between the different subnational areas in the same country as well as within the same subnational area across both capacity and quality subdomains. The analysis of the relationship between PHC service delivery and child health outcomes revealed that recent supervision (b=0.34, p<0.01) and supervisors' feedback (b=0.28, p<0.05) were each associated with increased care-seeking for pneumonia. We also observed the associations of several measures of capacity and quality with DPT immunisation. The analysis of maternal health outcomes yielded only a few statistically significant results at p<0.05 level, however, none remained significant after adjusting for other covariates. CONCLUSION The results of this analysis illustrate the heterogeneity in the capacity and quality of PHC service delivery within LMICs. Countries seeking to strengthen their PHC systems could improve PHC monitoring at the subnational level to better understand subnational bottlenecks in service delivery.
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Affiliation(s)
- Marwa Ramadan
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
| | | | - Cameron Feil
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
| | - Sarah Bolongaita
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
| | - Oscar Bernal
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
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Dohmen P, De Sanctis T, Waiyaiya E, Janssens W, Rinke de Wit T, Spieker N, Van der Graaf M, Van Raaij EM. Implementing value-based healthcare using a digital health exchange platform to improve pregnancy and childbirth outcomes in urban and rural Kenya. Front Public Health 2022; 10:1040094. [PMID: 36466488 PMCID: PMC9712749 DOI: 10.3389/fpubh.2022.1040094] [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: 09/08/2022] [Accepted: 11/01/2022] [Indexed: 11/18/2022] Open
Abstract
Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of the United Nations Sustainable Development Goal 3. Value-based healthcare (VBHC) has the potential to outperform traditional supply-driven approaches in changing this dismal situation, and significantly improve maternal, neonatal and child health (MNCH) outcomes. We developed a theory of change and used a cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated in Kenya. At the core of the approach was a value-based care bundle for maternity care, with predefined cost and quality of care using WHO guidelines and adjusted to the risk profile of the pregnancy. The care bundle was implemented using a digital exchange platform that connects pregnant women, clinics and payers. The platform manages financial transactions, enables bi-directional communication with pregnant women via SMS, collects data from clinics and shares enriched information via dashboards with payers and clinics. While the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a predictable cost per enrolled person. This community case study shows that implementation of the VBHC framework in an LMIC setting is possible for MNCH. The incremental, cohort-based approach enabled iterative learning processes. This can support the restructuring of health systems in low resource settings from an output-driven model to a value based financing-driven model.
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Affiliation(s)
- Peter Dohmen
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | | | | | - Wendy Janssens
- School of Business and Economics, VU Amsterdam, Amsterdam, Netherlands
- Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | - Tobias Rinke de Wit
- PharmAccess Foundation, Amsterdam, Netherlands
- Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Erik M. Van Raaij
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
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Khan A, Hamid S, Reza TE, Hanif K, Emmanuel F. Assessment of Effective Coverage of Antenatal Care and Associated Factors in Squatter Settlements of Islamabad Capital Territory, Pakistan: An Analytical Cross-Sectional Study. Cureus 2022; 14:e28454. [PMID: 36176884 PMCID: PMC9510716 DOI: 10.7759/cureus.28454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Effective coverage of antenatal care (ANC) goes beyond contact coverage and assesses the quality of service provided. We used World Health Organization’s recommended positive pregnancy guidelines to assess effective coverage and factors associated with the utilization of ANC among women in squatter settlements of Islamabad Capital Territory. Methods:We conducted a household survey in the study area with 416 women who had given birth in the past one year. Face-to-face interviews were conducted after the selection of study subjects was done through a systematic random sampling approach. Statistical analysis was carried out using Statistical Package for the Social Sciences 22 (SPSS 22; IBM corp. Armonk, NY). Effective ANC coverage was defined as four or more ANC visits along with all WHO-recommended interventions received at least once during ANC. Adjusted odds ratios (adjOR) with 95% CI were calculated using binary logistic regression to determine the independent effects of all associated factors on the outcome. Results: Of the 416 women interviewed, 399 (95.6%) had availed ANC services at least once. The coverage of 4+ ANC visits was 92% but effective coverage was only received by 35% women. The proportion of women who received nutritional interventions, maternal and fetal assessment and other preventive measures was 68%, 51% and 80.8% respectively. Maternal education (adjOR, 95% CI = 4.8[2.4-9.3]), family income (2.3[1.1-5.1]), multiparity (1.7[1.1-2.9]), place of first ANC visit (4.2[1.7-10.5]) and distance from a health facility (2.2[1.3-3.6]) were independently associated with the non-utilization of effective ANC. Conclusion: Despite a very high crude coverage of ANC services, the study shows a very low proportion of women receiving effective coverage. This stresses the importance of measuring the proportion of the population that receives health services with quality to monitor progress toward achieving universal health coverage.
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Endalamaw A, Gilks CF, Ambaw F, Assefa Y. Universality of universal health coverage: A scoping review. PLoS One 2022; 17:e0269507. [PMID: 35994455 PMCID: PMC9394787 DOI: 10.1371/journal.pone.0269507] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The progress of Universal health coverage (UHC) is measured using tracer indicators of key interventions, which have been implemented in healthcare system. UHC is about population, comprehensive health services and financial coverage for equitable quality services and health outcome. There is dearth of evidence about the extent of the universality of UHC in terms of types of health services, its integrated definition (dimensions) and tracer indicators utilized in the measurement of UHC. Therefore, we mapped the existing literature to assess universality of UHC and summarize the challenges towards UHC. METHODS The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews was used. A systematic search was carried out in the Web of Science and PubMed databases. Hand searches were also conducted to find articles from Google Scholar, the World Bank Library, the World Health Organization Library, the United Nations Digital Library Collections, and Google. Article search date was between 20 October 2021 and 12 November 2021 and the most recent update was done on 03 March 2022. Articles on UHC coverage, financial risk protection, quality of care, and inequity were included. The Population, Concept, and Context framework was used to determine the eligibility of research questions. A stepwise approach was used to identify and select relevant studies, conduct data charting, collation and summarization, as well as report results. Simple descriptive statistics and narrative synthesis were used to present the findings. RESULTS Forty-seven papers were included in the final review. One-fourth of the articles (25.5%) were from the African region and 29.8% were from lower-middle-income countries. More than half of the articles (54.1%) followed a quantitative research approach. Of included articles, coverage was assessed by 53.2% of articles; financial risk protection by 27.7%, inequity by 25.5% and quality by 6.4% of the articles as the main research objectives or mentioned in result section. Most (42.5%) of articles investigated health promotion and 2.1% palliation and rehabilitation services. Policy and healthcare level and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, weak regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned as a cross-cutting barrier. CONCLUSIONS The review showed that majority of the articles were from the African region. Methodologically, quantitative research design was more frequently used to investigate UHC. Palliation and rehabilitation health care services need attention in the monitoring and evaluation of UHC progress. It is also noteworthy to focus on quality and inequity of health services. The study implies that urgent action on the identified policy, health system and cross-cutting barriers is required to achieve UHC.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Charles F. Gilks
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Yibeltal Assefa
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Ferede Gebremedhin A, Dawson A, Hayen A. Evaluations of effective coverage of maternal and child health services: A systematic review. Health Policy Plan 2022; 37:895-914. [PMID: 35459943 PMCID: PMC9347022 DOI: 10.1093/heapol/czac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 03/25/2022] [Accepted: 04/21/2022] [Indexed: 11/27/2022] Open
Abstract
Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.
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Affiliation(s)
- Aster Ferede Gebremedhin
- Department of Public Health, College of Health Sciences, Debre Markos University, PO Box 269, Debre Markos, Ethiopia
- School of Public Health, University of Technology Sydney, PO Box 123, Broadway NSW 2007, Sydney, Australia
| | - Angela Dawson
- School of Public Health, University of Technology Sydney, PO Box 123, Broadway NSW 2007, Sydney, Australia
| | - Andrew Hayen
- School of Public Health, University of Technology Sydney, PO Box 123, Broadway NSW 2007, Sydney, Australia
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12
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Khatri RB, Durham J, Karkee R, Assefa Y. High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal? Reprod Health 2022; 19:163. [PMID: 35854265 PMCID: PMC9297647 DOI: 10.1186/s12978-022-01465-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal. METHODS We conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15-49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4+) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of "poor" and "optimal" quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed). RESULTS Contact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers. CONCLUSIONS Women experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period.
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Affiliation(s)
- Resham B Khatri
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia. .,Health Social Science and Development Research Institute, Kathmandu, Nepal.
| | - Jo Durham
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Rajendra Karkee
- School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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13
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Peters MA, Noonan CM, Rao KD, Edward A, Alonge OO. Evidence for an expanded hypertension care cascade in low- and middle-income countries: a scoping review. BMC Health Serv Res 2022; 22:827. [PMID: 35761254 PMCID: PMC9235242 DOI: 10.1186/s12913-022-08190-0] [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: 12/22/2021] [Accepted: 06/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background With nearly 90% of annual hypertension-related deaths occurring in low- and middle-income countries (LMICs), there is an urgent need to measure the coverage of health services that effectively manage hypertension. However, there is little agreement on how to define effective coverage and the existing hypertension care cascade (hypertension prevalence, percent aware, percent treated, and percent controlled) does not account for the quality of care received by patients. This study reviews definitions of effective coverage and service quality for hypertension management services and proposes an expanded hypertension care cascade to improve measurement of health systems performance. Methods A systematic scoping review of literature published in six electronic databases between January 2000 and October 2020 identified studies that defined effective coverage of hypertension management services or integrated dimensions of service quality into population-based estimates of hypertension management in LMICs. Findings informed an expanded hypertension care cascade from which quality-adjusted service coverage can be calculated to approximate effective coverage. Results The review identified 18 relevant studies, including 6 that defined effective coverage for hypertension management services and 12 that reported a measure of service quality in a population-based study. Based on commonly reported barriers to hypertension management, new steps on the proposed expanded care cascade include (i) population screened, (ii) population linked to quality care, and (iii) population adhering to prescribed treatment. Conclusion There is little consensus on the definition of effective coverage of hypertension management services, and most studies do not describe the quality of hypertension management services provided to populations. Incorporating aspects of service quality to the hypertension care cascade allows for the calculation of quality-adjusted coverage of relevant services, enabling an appropriate measurement of health systems performance through effective coverage. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08190-0.
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Affiliation(s)
- Michael A Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Caitlin M Noonan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Olakunle O Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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14
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Ramadan M, Tappis H, Brieger W. Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys. Confl Health 2022; 16:36. [PMID: 35706012 PMCID: PMC9202222 DOI: 10.1186/s13031-022-00466-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators. METHODS A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level. RESULTS Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity. CONCLUSION Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.
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Affiliation(s)
- Marwa Ramadan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Department of Community Medicine and Public Health, Alexandria University, Alexandria, Egypt.
| | - Hannah Tappis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Technical leadership and Innovations Office, Jhpiego, Baltimore, MD, USA
| | - William Brieger
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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15
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Exley J, Gupta PA, Schellenberg J, Strong KL, Requejo JH, Moller AB, Moran AC, Marchant T. A rapid systematic review and evidence synthesis of effective coverage measures and cascades for childbirth, newborn and child health in low- and middle-income countries. J Glob Health 2022; 12:04001. [PMID: 35136594 PMCID: PMC8801924 DOI: 10.7189/jogh.12.04001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Effective coverage measures aim to estimate the proportion of a population in need of a service that received a positive health outcome. In 2020, the Effective Coverage Think Tank Group recommended using a 'coverage cascade' for maternal, newborn, child and adolescent health and nutrition (MNCAHN), which organises components of effective coverage in a stepwise fashion, with each step accounting for different aspects of quality of care (QoC), applied at the population level. The cascade outlines six steps that increase the likelihood that the population in need experience the intended health benefit: 1) the population in need (target population) who contact a health service; 2) that has the inputs available to deliver the service; 3) who receive the health service; 4) according to quality standards; 5) and adhere to prescribed medication(s) or health workers instructions; and 6) experience the expected health outcome. We examined how effective coverage of life-saving interventions from childbirth to children aged nine has been defined and assessed which steps of the cascade are captured by existing measures. METHODS We undertook a rapid systematic review. Seven scientific literature databases were searched covering the period from May 1, 2017 to July, 8 2021. Reference lists from reviews published in 2018 and 2019 were examined to identify studies published prior to May 2017. Eligible studies reported population-level contact coverage measures adjusted for at least one dimension of QoC. RESULTS Based on these two search approaches this review includes literature published from 2010 to 2021. From 16 662 records reviewed, 33 studies were included, reporting 64 effective coverage measures. The most frequently examined measures were for childbirth and immediate newborn care (n = 24). No studies examined measures among children aged five to nine years. Definitions of effective coverage varied across studies. Key sources of variability included (i) whether a single effective coverage measure was reported for a package of interventions or separate measures were calculated for each intervention; (ii) the number and type of coverage cascade steps applied to adjust for QoC; and (iii) the individual items included in the effective coverage definition and the methods used to generate a composite quality measure. CONCLUSION In the MNCAHN literature there is substantial heterogeneity in both definitions and construction of effective coverage, limiting the comparability of measures over time and place. Current measurement approaches are not closely aligned with the proposed cascade. For widespread adoption, there is a need for greater standardisation of indicator definitions and transparency in reporting, so governments can use these measures to improve investments in MNACHN and implement life-saving health policies and programs.
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Affiliation(s)
- Josephine Exley
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Prateek Anand Gupta
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Kathleen L Strong
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Jennifer Harris Requejo
- Division of Data, Analytics, Planning & Monitoring, United Nations Children’s Fund, New York, USA
| | - Ann-Beth Moller
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Child Health Accountability Tracking Technical Advisory Group (CHAT) and the Mother and Newborn Information for Tracking Outcomes and Results Technical Advisory Group (MoNITOR)
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
- Division of Data, Analytics, Planning & Monitoring, United Nations Children’s Fund, New York, USA
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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16
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Oyando R, Barasa E, Ataguba JE. Socioeconomic Inequity in the Screening and Treatment of Hypertension in Kenya: Evidence From a National Survey. FRONTIERS IN HEALTH SERVICES 2022; 2:786098. [PMID: 36925851 PMCID: PMC10012826 DOI: 10.3389/frhs.2022.786098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022]
Abstract
Background Non-communicable diseases (NCDs) account for 50% of hospitalisations and 55% of inpatient deaths in Kenya. Hypertension is one of the major NCDs in Kenya. Equitable access and utilisation of screening and treatment interventions are critical for reducing the burden of hypertension. This study assessed horizontal equity (equal treatment for equal need) in the screening and treatment for hypertension. It also decomposed socioeconomic inequalities in care use in Kenya. Methods Cross-sectional data from the 2015 NCDs risk factors STEPwise survey, covering 4,500 adults aged 18-69 years were analysed. Socioeconomic inequality was assessed using concentration curves and concentration indices (CI), and inequity by the horizontal inequity (HI) index. A positive (negative) CI or HI value suggests a pro-rich (pro-poor) inequality or inequity. Socioeconomic inequality in screening and treatment for hypertension was decomposed into contributions of need [age, sex, and body mass index (BMI)] and non-need (wealth status, education, exposure to media, employment, and area of residence) factors using a standard decomposition method. Results The need for hypertension screening was higher among poorer than wealthier socioeconomic groups (CI = -0.077; p < 0.05). However, wealthier groups needed hypertension treatment more than poorer groups (CI = 0.293; p <0.001). Inequity in the use of hypertension screening (HI = 0.185; p < 0.001) and treatment (HI = 0.095; p < 0.001) were significantly pro-rich. Need factors such as sex and BMI were the largest contributors to inequalities in the use of screening services. By contrast, non-need factors like the area of residence, wealth, and employment status mainly contributed to inequalities in the utilisation of treatment services. Conclusion Among other things, the use of hypertension screening and treatment services in Kenya should be according to need to realise the Sustainable Development Goals for NCDs. Specifically, efforts to attain equity in healthcare use for hypertension services should be multi-sectoral and focused on crucial inequity drivers such as regional disparities in care use, poverty and educational attainment. Also, concerted awareness campaigns are needed to increase the uptake of screening services for hypertension.
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Affiliation(s)
- Robinson Oyando
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Health Economics Unit, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John E Ataguba
- Health Economics Unit, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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17
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King SE, Sheffel A, Heidkamp R, Xu YY, Walton S, Munos MK. Advancing nutrition measurement: Developing quantitative measures of nutrition service quality for pregnant women and children in low‐ and middle‐income country health systems. MATERNAL & CHILD NUTRITION 2022; 18:e13279. [PMID: 34734469 PMCID: PMC8710116 DOI: 10.1111/mcn.13279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Shannon E. King
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Ashley Sheffel
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Rebecca Heidkamp
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Yvonne Yiru Xu
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Shelley Walton
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Melinda K. Munos
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
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18
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Exley J, Bhattacharya A, Hanson C, Shuaibu A, Umar N, Marchant T. Operationalising effective coverage measurement of facility based childbirth in Gombe State; a comparison of data sources. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000359. [PMID: 36962182 PMCID: PMC10021305 DOI: 10.1371/journal.pgph.0000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/22/2022] [Indexed: 11/18/2022]
Abstract
Estimating effective coverage of childbirth care requires linking population based data sources to health facility data. For effective coverage to gain widespread adoption there is a need to focus on the feasibility of constructing these measures using data typically available to decision makers in low resource settings. We estimated effective coverage of childbirth care in Gombe State, northeast Nigeria, using two different combinations of facility data sources and examined their strengths and limitations for decision makers. Effective coverage captures information on four steps: access, facility inputs, receipt of interventions and process quality. We linked data from the 2018 Nigerian Demographic and Health Survey (NDHS) to two sources of health facility data: (1) comprehensive health facility survey data generated by a research project; and (2) District Health Information Software 2 (DHIS2). For each combination of data sources, we examined which steps were feasible to calculate, the size of the drop in coverage between steps and the resulting estimate of effective coverage. Analysis included 822 women with a recent live birth, 30% of whom attended a facility for childbirth. Effective coverage was low: 2% based on the project data and less than 1% using the DHIS2. Linking project data with NDHS, it was feasible to measure all four steps; using DHIS2 it was possible to estimate three steps: no data was available to measure process quality. The provision of high quality care is suboptimal in this high mortality setting where access and facility readiness to provide care, crucial foundations to the provision of high quality of care, have not yet been met. This study demonstrates that partial effective coverage measures can be constructed from routine data combined with nationally representative surveys. Advocacy to include process of care indicators in facility summary reports could optimise this data source for decision making.
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Affiliation(s)
- Josephine Exley
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Antoinette Bhattacharya
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Public Health Sciences-Global Health, Karolinska Institutet, Stockholm, Sweden
| | - Abdulrahman Shuaibu
- The Executive Secretary, Gombe State Primary Health Care Development Agency, Gombe, Nigeria
| | - Nasir Umar
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
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19
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Leslie HH, Hategeka C, Ndour PI, Nimako K, Dieng M, Diallo A, Ndiaye Y. Stability of healthcare quality measures for maternal and child services: Analysis of the continuous service provision assessment of health facilities in Senegal, 2012-2018. Trop Med Int Health 2021; 27:68-80. [PMID: 34865274 PMCID: PMC9300084 DOI: 10.1111/tmi.13701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective High‐quality healthcare is essential to ensuring maternal and newborn survival. Efficient measurement requires knowing how long measures of quality provide consistent insight for intended uses. Methods We used a repeated health facility assessment in Senegal to calculate structural and process quality of antenatal care (ANC), delivery and child health services in facilities assessed 2 years apart. We tested agreement of quality measures within facilities and regions. We estimated how much input‐adjusted and process quality‐adjusted coverage measures changed for each service when calculated using quality measurements from the same facilities measured 2 years apart. Results Over 6 waves of continuous surveys, 628 paired assessments were completed. Changes at the facility level were substantial and often positive, but inconsistent. Structural quality measures were moderately correlated (0.40–0.69) within facilities over time, more so in hospitals; correlation was <0.20 for process measures based on direct observation of ANC and child visits. Most measures were more strongly correlated once averaged to regions; process quality of child services was not (−0.32). Median relative difference in national‐adjusted coverage estimates was 6.0%; differences in subnational estimates were largest for process quality of child services (19.6%). Conclusion Continuous measures of structural quality demonstrated consistency at regional levels and in higher level facilities over 2 years; results for process measures were mixed. Direct observation of child visits provided inconsistent measures over time. For other measures, linking population data with health facility assessments from up to 2 years prior is likely to introduce modest measurement error in adjusted coverage estimates.
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Affiliation(s)
- Hannah H Leslie
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Celestin Hategeka
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Papa Ibrahima Ndour
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal.,Agence Nationale de la Démographie et de la Statistique, Dakar, Senegal
| | | | - Mamadou Dieng
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal
| | - Abdoulaye Diallo
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal
| | - Youssoupha Ndiaye
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal
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20
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Chukwuma A, Wong KLM, Ekhator-Mobayode UE. Disrupted Service Delivery? The Impact of Conflict on Antenatal Care Quality in Kenya. Front Glob Womens Health 2021; 2:599731. [PMID: 34816176 PMCID: PMC8594042 DOI: 10.3389/fgwh.2021.599731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/28/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: African countries facing conflict have higher levels of maternal mortality. Understanding the gaps in the utilization of high-quality maternal health care is essential to improving maternal survival in these states. Few studies have estimated the impact of conflict on the quality of health care. In this study, we estimated the impact of conflict on the quality of health care in Kenya, a country with multiple overlapping conflicts and significant disparities in maternal survival. Materials and Methods: We drew on data on the observed quality of 553 antenatal care (ANC) visits between January and April 2010. Process quality was measured as the percentage of elements of client–provider interactions performed in these visits. For structural quality, we measured the percentage of required components of equipment and infrastructure and the management and supervision in the facility on the day of the visit. We spatially linked the analytical sample to conflict events from January to April 2010. We modeled the quality of ANC as a function of exposure to conflict using spatial difference-in-difference models. Results: ANC visits that occurred in facilities within 10,000 m of any conflict event in a high-conflict month received 18–21 percentage points fewer components of process quality on average and had a mean management and supervision score that was 12.8–13.5 percentage points higher. There was no significant difference in the mean equipment and infrastructure score at the 5% level. The positive impact of conflict exposure on the quality of management and supervision was driven by rural facilities. The quality of management and supervision and equipment and infrastructure did not modify the impact of conflict on process quality. Discussion: Our study demonstrates the importance of designing maternal health policy based on the context-specific evidence on the mechanisms through which conflict affects health care. In Kenya, deterioration of equipment and infrastructure does not appear to be the main mechanism through which conflict has affected ANC quality. Further research should focus on better understanding the determinants of the gaps in process quality in conflict-affected settings, including provider motivation, competence, and incentives.
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Affiliation(s)
| | - Kerry L M Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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21
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Anindya K, Marthias T, Vellakkal S, Carvalho N, Atun R, Morgan A, Zhao Y, Hulse ESG, McPake B, Lee JT. Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries. EClinicalMedicine 2021; 40:101103. [PMID: 34527893 PMCID: PMC8430373 DOI: 10.1016/j.eclinm.2021.101103] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs). METHODS Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index. FINDINGS The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries. INTERPRETATION Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries. FUNDING None.
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Affiliation(s)
- Kanya Anindya
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Tiara Marthias
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Department of Public Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Sukumar Vellakkal
- Department of Economic Sciences, Indian Institute of Technology Kanpur, Kalyanpur, Uttar Pradesh, India
| | - Natalie Carvalho
- Center for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Alison Morgan
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Global Financing Facility, The World Bank Group, Washington, DC, United States
| | - Yang Zhao
- WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne, VIC, Australia
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Emily SG Hulse
- Center for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - John Tayu Lee
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
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22
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Carter ED, Leslie HH, Marchant T, Amouzou A, Munos MK. Methodological considerations for linking household and healthcare provider data for estimating effective coverage: a systematic review. BMJ Open 2021; 11:e045704. [PMID: 34446481 PMCID: PMC8395298 DOI: 10.1136/bmjopen-2020-045704] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To assess existing knowledge related to methodological considerations for linking population-based surveys and health facility data to generate effective coverage estimates. Effective coverage estimates the proportion of individuals in need of an intervention who receive it with sufficient quality to achieve health benefit. DESIGN Systematic review of available literature. DATA SOURCES Medline, Carolina Population Health Center and Demographic and Health Survey publications and handsearch of related or referenced works of all articles included in full text review. The search included publications from 1 January 2000 to 29 March 2021. ELIGIBILITY CRITERIA Publications explicitly evaluating (1) the suitability of data, (2) the implications of the design of existing data sources and (3) the impact of choice of method for combining datasets to obtain linked coverage estimates. RESULTS Of 3805 papers reviewed, 70 publications addressed relevant issues. Limited data suggest household surveys can be used to identify sources of care, but their validity in estimating intervention need was variable. Methods for collecting provider data and constructing quality indices were diverse and presented limitations. There was little empirical data supporting an association between structural, process and outcome quality. Few studies addressed the influence of the design of common data sources on linking analyses, including imprecise household geographical information system data, provider sampling design and estimate stability. The most consistent evidence suggested under certain conditions, combining data based on geographical proximity or administrative catchment (ecological linking) produced similar estimates to linking based on the specific provider utilised (exact match linking). CONCLUSIONS Linking household and healthcare provider data can leverage existing data sources to generate more informative estimates of intervention coverage and care. However, existing evidence on methods for linking data for effective coverage estimation are variable and numerous methodological questions remain. There is need for additional research to develop evidence-based, standardised best practices for these analyses.
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Affiliation(s)
- Emily D Carter
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hannah H Leslie
- Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Tanya Marchant
- Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Agbessi Amouzou
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Giessler K, Seefeld A, Montagu D, Phillips B, Mwangi J, Munson M, Green C, Opot J, Golub G. Perspectives on implementing a quality improvement collaborative to improve person-centered care for maternal and reproductive health in Kenya. Int J Qual Health Care 2020; 32:671-676. [PMID: 33057658 PMCID: PMC7737155 DOI: 10.1093/intqhc/mzaa130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/18/2020] [Accepted: 10/13/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To understand perspectives and experiences related to participation in a quality improvement collaborative (QIC) to improve person-centered care (PCC) for maternal health and family planning (FP) in Kenya. DESIGN AND SETTING Semi-structured qualitative interviews were conducted with members of the QIC in four public health facilities in Kenya. PARTICIPANTS Clinical and nonclinical public health facility staff who had participated in the QIC were purposively sampled to participate in the semi-structured interviews. INTERVENTION A QIC was implemented across four public health facilities in Nairobi and Kiambu Counties in Kenya to improve PCC experiences for women seeking maternity or FP services. MAIN OUTCOME MEASURE Semi-structured interviews with participants of the QIC to understand perspectives and experiences associated with sensitization to and implementation of PCC behaviors in maternity and FP services. RESULTS Respondents reported that sensitization to PCC principles resulted in multiple perceived benefits for staff and patients alike, including improved interactions with patients and clients, deeper awareness of patient and client preferences, and improved interpersonal skills and greater job satisfaction. Respondents also highlighted system-level challenges that impeded their ability to consistently provide high-quality PCC to women, namely staff shortages and frequent turnover, high patient volumes and lack of space in their respective health facilities. CONCLUSION Respondents were easily able to articulate perceived benefits derived from participation in this QIC, although they were equally able to identify challenges that hindered their ability to consistently provide high-quality PCC to women seeking maternity or FP services.
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Affiliation(s)
- Katie Giessler
- Institute for Global Health Sciences, University of California, San Francisco, Mission Hall, Box 1224, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - Avery Seefeld
- Institute for Global Health Sciences, University of California, San Francisco, Mission Hall, Box 1224, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - Dominic Montagu
- Institute for Global Health Sciences, University of California, San Francisco, Mission Hall, Box 1224, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - Beth Phillips
- Institute for Global Health Sciences, University of California, San Francisco, Mission Hall, Box 1224, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA
| | - James Mwangi
- Jacaranda Health, Nairobi, Kenya, Diani Close, Nairobi, Kenya
| | - Meghan Munson
- Jacaranda Health, Nairobi, Kenya, Diani Close, Nairobi, Kenya
| | - Cathy Green
- Jacaranda Health, Nairobi, Kenya, Diani Close, Nairobi, Kenya
| | - James Opot
- Innovations for Poverty Action, Sandalwood Lane, Nairobi, Kenya
| | - Ginger Golub
- Innovations for Poverty Action, Sandalwood Lane, Nairobi, Kenya
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Yakob B, Gage A, Nigatu TG, Hurlburt S, Hagos S, Dinsa G, Bowser D, Berman P, Kruk ME, Tekle E. Low effective coverage of family planning and antenatal care services in Ethiopia. Int J Qual Health Care 2020; 31:725-732. [PMID: 30608585 DOI: 10.1093/intqhc/mzy251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/29/2018] [Accepted: 12/14/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess the quality and effective coverage (EC) of family planning (FP) and antenatal care (ANC) services in Ethiopia. DESIGN Secondary analyses of the 2014 Ethiopia Service Provision Assessment Plus Survey and 2016 Ethiopia Demographic and Health Survey data. SETTING AND PARTICIPANTS Women using FP and ANC. MAIN OUTCOME MEASURES Quality indices are created as a proportion of recommended clinical actions done in observations of ANC and FP visits. We adjust the crude coverage of ANC and of FP by the quality to estimate EC for both services. RESULTS The crude coverage of FP was 61% and 62% for ANC in Ethiopia in 2016. On average, quality was 35.8% during FP visits and 86% of women received <50% of the recommended clinical actions. When adjusting the crude coverage to account for the quality of service, Ethiopia's FP services EC was 22%. On average, ANC quality was 34% and 81% received <50% of the recommended ANC clinical actions. When adjusting the crude coverage by the service quality, the mean EC of ANC services was 22% in Ethiopia. CONCLUSIONS The quality of both FP and ANC services is low in Ethiopia, with women obtaining only a fraction of the standard clinical actions during their visits. In addition, there is considerable variation in EC across Ethiopia's regions, with variation driven largely by variations in crude coverage. To improve EC, actions are needed to improve the quality of ANC and FP care.
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Affiliation(s)
- Bereket Yakob
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Fenot Project, Addis Ababa, Ethiopia
| | - Anna Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Ave., Building 1, Boston, MA 02115, USA
| | - Tsinuel Girma Nigatu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Fenot Project, Addis Ababa, Ethiopia
| | - Sarah Hurlburt
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Fenot Project, Addis Ababa, Ethiopia
| | - Seifu Hagos
- School of Public Health, Fenot Project, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girmaye Dinsa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Fenot Project, Addis Ababa, Ethiopia
| | - Diana Bowser
- Heller School for Social Policy and Management, Brandeis University 415 South St, Waltham, MA, USA
| | - Peter Berman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Ave., Building 1, Boston, MA 02115, USA.,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, Canada
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Ave., Building 1, Boston, MA 02115, USA
| | - Ephrem Tekle
- Maternal and Child Health Directorate, Ministry of Health, Federal Democratic Republic of Ethiopia, Addis Ababa, Ethiopia
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Sauer SM, Pullum T, Wang W, Mallick L, Leslie HH. Variance estimation for effective coverage measures: A simulation study. J Glob Health 2020; 10:010506. [DOI: 10.7189/jogh.10.010506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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26
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Marsh AD, Muzigaba M, Diaz T, Requejo J, Jackson D, Chou D, Cresswell JA, Guthold R, Moran AC, Strong KL, Banerjee A, Soucat A. Effective coverage measurement in maternal, newborn, child, and adolescent health and nutrition: progress, future prospects, and implications for quality health systems. Lancet Glob Health 2020; 8:e730-e736. [PMID: 32353320 PMCID: PMC7196884 DOI: 10.1016/s2214-109x(20)30104-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 12/25/2022]
Abstract
Intervention coverage-the proportion of the population with a health-care need who receive care-does not account for intervention quality and potentially overestimates health benefits of services provided to populations. Effective coverage introduces the dimension of quality of care to the measurement of intervention coverage. Many definitions and methodological approaches to measuring effective coverage have been developed, resulting in confusion over definition, calculation, interpretation, and monitoring of these measures. To develop a consensus on the definition and measurement of effective coverage for maternal, newborn, child, and adolescent health and nutrition (MNCAHN), WHO and UNICEF convened a group of experts, the Effective Coverage Think Tank Group, to make recommendations for standardising the definition of effective coverage, measurement approaches for effective coverage, indicators of effective coverage in MNCAHN, and to develop future effective coverage research priorities. Via a series of consultations, the group recommended that effective coverage be defined as the proportion of a population in need of a service that resulted in a positive health outcome from the service. The proposed effective coverage measures and care cascade steps can be applied to further develop effective coverage measures across a broad range of MNCAHN services. Furthermore, advances in measurement of effective coverage could improve monitoring efforts towards the achievement of universal health coverage.
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Affiliation(s)
| | - Moise Muzigaba
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Theresa Diaz
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland.
| | - Jennifer Requejo
- Division of Data, Analysis, Planning and Monitoring, United Nations Children's Fund, Headquarters, New York, NY, USA
| | - Debra Jackson
- Health Division, United Nations Children's Fund, Headquarters, New York, NY, USA; School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Doris Chou
- Department of Sexual and Reproductive Health and Research including the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Jenny A Cresswell
- Department of Sexual and Reproductive Health and Research including the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Regina Guthold
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Kathleen L Strong
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Anshu Banerjee
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Agnès Soucat
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
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Sauer SM, Pullum T, Wang W, Mallick L, Leslie HH. Variance estimation for effective coverage measures: A simulation study. J Glob Health 2020. [PMID: 32257160 PMCID: PMC7101480 DOI: 10.7189/jogh-10-010506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Effective coverage research is increasing rapidly in global health and development, as researchers use a range of measures and combine data sources to adjust coverage for the quality of services received. However, most estimates of effective coverage that combine data sources are reported only as point estimates, which may be due to the challenge of calculating the variance for a composite measure. In this paper, we evaluate three methods to quantify the uncertainty in the estimation of effective coverage. Methods We conducted a simulation study to evaluate the performance of the exact, delta, and parametric bootstrap methods for constructing confidence intervals around point estimates that are calculated from combined data on coverage and quality. We assessed performance by computing the number of nominally 95% confidence intervals that contain the truth for a range of coverage and quality values and data source sample sizes. To illustrate these approaches, we applied the delta and exact methods to estimates of adjusted coverage of antenatal care (ANC) in Senegal. We used household survey data for coverage and health facility assessments for readiness to provide services. Results With small sample sizes, when the true effective coverage value was close to the boundaries 0 or 1, the exact and parametric bootstrap methods resulted in substantial over or undercoverage and, for the exact method, a high proportion of invalid confidence intervals, while the delta method yielded modest overcoverage. The proportion of confidence intervals containing the truth in all three methods approached the intended 95% with larger sample sizes and as the true effective coverage value moved away from the 0 or 1 boundary. Confidence intervals for adjusted ANC in Senegal were largely overlapping across the delta and exact methods, although at the sub-national level, the exact method produced invalid confidence intervals for estimates near 0 or 1. We provide the code to implement these methods. Conclusions The uncertainty around an effective coverage estimate can be characterized; this should become standard practice if effective coverage estimates are to become part of national and global health monitoring. The delta method approach outperformed the other methods in this study; we recommend its use for appropriate inference from effective coverage estimates that combine data sources, particularly when either sample size is small. When used for estimates created from facility type or regional strata, these methods require assumptions of independence that must be considered in each example.
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Affiliation(s)
- Sara M Sauer
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Thomas Pullum
- The Demographic and Health Surveys (DHS) Program, Division of International Health and Development, ICF, Rockville, Maryland, USA
| | - Wenjuan Wang
- The Demographic and Health Surveys (DHS) Program, Division of International Health and Development, ICF, Rockville, Maryland, USA.,Division of AIDS, Behavioral, and Population Sciences; Center for Scientific Review, National Institutes of Health; Bethesda, Maryland, USA
| | - Lindsay Mallick
- The DHS Program, Avenir Health; Glastonbury, Connecticut, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Joseph NT, Piwoz E, Lee D, Malata A, Leslie HH. Examining coverage, content, and impact of maternal nutrition interventions: the case for quality-adjusted coverage measurement. J Glob Health 2020; 10:010501. [PMID: 32082545 PMCID: PMC7020656 DOI: 10.7189/jogh.10.010501] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Reductions in neonatal mortality remain stagnant, despite gains in health care access and utilization. Nutrition interventions during antenatal care (ANC) and in the immediate postpartum period are associated with improved neonatal outcomes. Adjusting coverage estimates for the quality of care provided yields greater insight into health system performance and potential population health benefits of accessing care. In this cross-sectional study, we adjust maternity care coverage measures for quality of nutrition interventions to determine the impact on infant birth weight and breastfeeding. Methods We used household data from the Malawi 2013-2014 Multiple Indicator Cluster Survey to assess use of maternal health services and direct observations of ANC and delivery from the 2013 Service Provision Assessment to measure nutrition interventions provided. We adjusted coverage measures combining self-reported utilization of care with the likelihood of receipt of nutrition interventions. Using adjusted log-linear regression, we estimated the associations of these nutrition quality-adjusted metrics with infant birthweight and immediate breastfeeding. Results Health facility data provided over 2500 directly observed clinical encounters and household data provided 7385 individual reports of health care utilization and outcomes. Utilization of ANC and facility-delivery was high. Women received nutrition-related interventions considerably less often than they sought care: over the course of ANC women received a median of 1.6 interventions on iron, 1 instance of nutrition counseling, and 0.06 instances of breastfeeding counseling. Nutrition quality-adjusted ANC coverage was associated with a reduced risk of low birthweight (adjusted relative risk [ARR] 0.87, 95% confidence interval (CI) = 0.79, 0.96) and increased likelihood of immediate breastfeeding (ARR = 1.04, 95% CI = 1.02, 1.07); nutrition quality-adjusted post-delivery care was also associated with greater uptake of immediate breastfeeding (ARR = 1.08, 95% CI = 1.02, 1.14). Based on these models, delivering nutrition interventions consistently within the existing level of coverage would decrease population prevalence of low birthweight from 13.7% to 10.8% and increase population prevalence of immediate breastfeeding from 75.9% to 86.0%. Conclusions Linking household survey data to health service provision assessments demonstrates that despite high utilization of maternal health services in Malawi, low provision of nutrition interventions is undermining infant health. Substantial gains in newborn health are possible in Malawi if quality of existing services is strengthened.
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Affiliation(s)
- Naima T Joseph
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ellen Piwoz
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Dennis Lee
- Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Address Malata
- Malawi University of Science and Technology, Limbe, Malawi
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
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Abstract
INTRODUCTION Measuring quality of care in low-income and middle-income countries is complicated by the lack of a standard, universally accepted definition for 'quality' for any particular service, as well as limited guidance on which indicators to include in measures of quality of care, and how to incorporate those indicators into summary indices. The aim of this paper is to develop, characterise and compare a set of antenatal care (ANC) indices for facility readiness and provision of care. METHODS We created nine indices for facility readiness using three methods for selecting items and three methods for combining items. In addition, we created three indices for provision of care using one method for selecting items and three methods for combining items. For each index, we calculated descriptive statistics, categorised the continuous index scores using tercile cut points to assess comparability of facility classification, and examined the variability and distribution of scores. RESULTS Our results showed that, within a country, the indices were quite similar in terms of mean index score, facility classification, coefficient of variation, floor and ceiling effects, and the inclusion of items in an index with a range of variability. Notably, the indices created using principal components analysis to combine the items were the most different from the other indices. In addition, the index created by taking a weighted average of a core set of items had lower agreement with the other indices when looking at facility classification. CONCLUSIONS As improving quality of care becomes integral to global efforts to produce better health outcomes, demand for guidance on creating standardised measures of service quality will grow. This study provides health systems researchers with a comparison of methodologies commonly used to create summary indices of ANC service quality and it highlights the similarities and differences between methods.
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Affiliation(s)
- Ashley Sheffel
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Scott Zeger
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca Heidkamp
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda Kay Munos
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Al-Shammari I, Roa L, Yorlets RR, Akerman C, Dekker A, Kelley T, Koech R, Mutuku J, Nyarango R, Nzorubara D, Spieker N, Vaidya M, Meara JG, Ljungman D. Implementation of an international standardized set of outcome indicators in pregnancy and childbirth in Kenya: Utilizing mobile technology to collect patient-reported outcomes. PLoS One 2019; 14:e0222978. [PMID: 31618249 PMCID: PMC6795527 DOI: 10.1371/journal.pone.0222978] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/11/2019] [Indexed: 11/29/2022] Open
Abstract
Background Limited data exist on health outcomes during pregnancy and childbirth in low- and middle-income countries. This is a pilot of an innovative data collection tool using mobile technology to collect patient-reported outcome measures (PROMs) selected from the International Consortium of Health Outcomes Measurement (ICHOM) Pregnancy and Childbirth Standard Set in Nairobi, Kenya. Methods Pregnant women in the third trimester were recruited at three primary care facilities in Nairobi and followed prospectively throughout delivery and until six weeks postpartum. PROMs were collected via mobile surveys at three antenatal and two postnatal time points. Outcomes included incontinence, dyspareunia, mental health, breastfeeding and satisfaction with care. Hospitals reported morbidity and mortality. Descriptive statistics on maternal and child outcomes, survey completion and follow-up rates were calculated. Results In six months, 204 women were recruited: 50% of women returned for a second ante-natal care visit, 50% delivered at referral hospitals and 51% completed the postnatal visit. The completion rates for the five PROM surveys were highest at the first antenatal care visit (92%) and lowest in the postnatal care visit (38%). Data on depression, dyspareunia, fecal and urinary incontinence were successfully collected during the antenatal and postnatal period. At six weeks postpartum, 86% of women breastfeed exclusively. Most women that completed the survey were very satisfied with antenatal care (66%), delivery care (51%), and post-natal care (60%). Conclusion We have demonstrated that it is feasible to use mobile technology to follow women throughout pregnancy, track their attendance to pre-natal and post-natal care visits and obtain data on PROM. This study demonstrates the potential of mobile technology to collect PROM in a low-resource setting. The data provide insight into the quality of maternal care services provided and will be used to identify and address gaps in access and provision of high quality care to pregnant women.
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Affiliation(s)
- Ishtar Al-Shammari
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, United States of America
| | - Lina Roa
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Canada
- * E-mail:
| | - Rachel R. Yorlets
- Department of Plastic & Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Christina Akerman
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, United States of America
| | | | - Thomas Kelley
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, United States of America
| | | | - Judy Mutuku
- Gertrude’s Children’s Hospital, Nairobi, Kenya
| | | | | | | | | | - John G. Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Plastic & Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - David Ljungman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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31
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Amouzou A, Leslie HH, Ram M, Fox M, Jiwani SS, Requejo J, Marchant T, Munos MK, Vaz LME, Weiss W, Hayashi C, Boerma T. Advances in the measurement of coverage for RMNCH and nutrition: from contact to effective coverage. BMJ Glob Health 2019; 4:e001297. [PMID: 31297252 PMCID: PMC6590972 DOI: 10.1136/bmjgh-2018-001297] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/28/2019] [Accepted: 04/06/2019] [Indexed: 11/17/2022] Open
Abstract
Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches.
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Affiliation(s)
- Agbessi Amouzou
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hannah Hogan Leslie
- Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Malathi Ram
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Monica Fox
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Safia S Jiwani
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer Requejo
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.,Data and Analytics Section, Division of Data, Research and Policy, UNICEF USA, New York, New York, USA
| | - Tanya Marchant
- Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Melinda Kay Munos
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lara M E Vaz
- Global Health, Save the Children, Fairfield, Connecticut, USA
| | - William Weiss
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chika Hayashi
- Data and Analytics Section, Division of Data, Research and Policy, UNICEF USA, New York, New York, USA
| | - Ties Boerma
- Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Kabia E, Mbau R, Oyando R, Oduor C, Bigogo G, Khagayi S, Barasa E. "We are called the et cetera": experiences of the poor with health financing reforms that target them in Kenya. Int J Equity Health 2019; 18:98. [PMID: 31234940 PMCID: PMC6591805 DOI: 10.1186/s12939-019-1006-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Through a number of healthcare reforms, Kenya has demonstrated its intention to extend financial risk protection and service coverage for poor and vulnerable groups. These reforms include the provision of free maternity services, user-fee removal in public primary health facilities and a health insurance subsidy programme (HISP) for the poor. However, the available evidence points to inequity and the likelihood that the poor will still be left behind with regards to financial risk protection and service coverage. This study examined the experiences of the poor with health financing reforms that target them. METHODS We conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through focus group discussions (n = 8) and in-depth interviews (n = 30) with people in the lowest wealth quintile residing in the health and demographic surveillance systems, and HISP beneficiaries. We analyzed the data using a framework approach focusing on four healthcare access dimensions; geographical accessibility, affordability, availability, and acceptability. RESULTS Health financing reforms reduced financial barriers and improved access to health services for the poor in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that HISP beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among the poor. CONCLUSIONS Pro-poor health financing reforms improved access to care for the poor to some extent. However, to enhance the effectiveness of pro-poor reforms and to ensure that the poor in Kenya benefit fully from them, there is a need to address barriers to healthcare seeking across all access dimensions.
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Affiliation(s)
- Evelyn Kabia
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Rahab Mbau
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Robinson Oyando
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Clement Oduor
- African Population and Health Research Centre, Nairobi, Kenya
| | | | - Sammy Khagayi
- KEMRI-Centre for Global Health Research, Kisumu, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Wang W, Mallick L, Allen C, Pullum T. Effective coverage of facility delivery in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania. PLoS One 2019; 14:e0217853. [PMID: 31185020 PMCID: PMC6559642 DOI: 10.1371/journal.pone.0217853] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/19/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The persistence of preventable maternal and newborn deaths highlights the importance of quality of care as an essential element in coverage interventions. Moving beyond the conventional measurement of crude coverage, we estimated effective coverage of facility delivery by adjusting for facility preparedness to provide delivery services in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania. METHODS The study uses data from Demographic and Health Surveys (DHS) and Service Provision Assessments (SPA) in Bangladesh (2014 DHS and 2014 SPA), Haiti (2012 DHS and 2013 SPA), Malawi (2015-16 DHS and 2013-14 SPA), Nepal (2016 DHS and 2015 SPA), Senegal (2016 DHS and 2015 SPA), and Tanzania (2015-16 DHS and 2014-15 SPA). We defined effective coverage as the mathematical product of crude coverage and quality of care. The coverage of facility delivery was measured with DHS data and quality of care was measured with facility data from SPA. We estimated effective coverage at both the regional and the national level and accounted for type of facility where delivery care was sought. FINDINGS The findings from the six countries indicate the effective coverage ranges from 24% in Haiti to 66% in Malawi, representing substantial reductions (20% to 39%) from crude coverage rates. Although Malawi has achieved almost universal coverage of facility delivery (93%), effective coverage was only 66%.vSuch gaps between the crude coverage and the effective coverage suggest that women delivered in health facility but did not necessarily receive an adequate quality of care. In all countries except Malawi, effective coverage differed substantially among the country's regions of the country, primarily due to regional variability in coverage. INTERPRETATION Our findings reinforce the importance of quality of obstetric and newborn care to achieve further reduction of maternal and newborn mortality. Continued efforts are needed to increase the use of facility delivery service in countries or regions where coverage remains low.
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Affiliation(s)
- Wenjuan Wang
- The Demographic and Health Surveys (DHS) Program, Division of International Health and Development, ICF, Rockville, Maryland, United States of America
| | - Lindsay Mallick
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Courtney Allen
- The Demographic and Health Surveys (DHS) Program, Division of International Health and Development, ICF, Rockville, Maryland, United States of America
| | - Thomas Pullum
- The Demographic and Health Surveys (DHS) Program, Division of International Health and Development, ICF, Rockville, Maryland, United States of America
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Hu Y, Chen Y, Wang Y, Liang H. Validity of Maternal Recall to Assess Vaccination Coverage: Evidence from Six Districts in Zhejiang Province, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16060957. [PMID: 30889780 PMCID: PMC6466224 DOI: 10.3390/ijerph16060957] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 01/30/2023]
Abstract
Background: Although recall-based data are collected by survey when the vaccination records are not available, the preferred estimates remain the record-based ones due to the limited validity of recall-based data. However, the evidence on validity of maternal recalls is limited and varied across vaccine types. To close the gaps, we validated the maternal recall on vaccination against record-based data in six districts in Zhejiang Province, China. Methods: We used a cross-sectional survey of about 648 households with mothers who delivered in the last 12 months prior to the survey in October 2017, from six districts in Zhejiang Province. Vaccination status on five vaccine types scheduled before 12 months of age were collected through maternal recall and vaccination records. The level of agreement and recall bias between the two resources, the sensitivity and specificity of maternal recall were evaluated. Risk factors for maternal recall bias were also identified through logistic regression model for each type of vaccine. Results: The level of agreement between recall and record was above 90% across vaccine types, with the recall bias ranged from 2.2% to 9.7%. Recall bias due to over-reporting was slightly higher than that due to under-reporting. Recall bias was positively associated with high parity, home delivery, younger mothers, mothers with low education, and migrant mothers. Conclusions: This study indicated most of the vaccination status across vaccine types was accurately identified through maternal recall and supported the use of maternal recall to estimate the vaccination coverage as an alternative in the absence of record-based data.
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Affiliation(s)
- Yu Hu
- Institute of Immunization and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310000, China.
| | - Yaping Chen
- Institute of Immunization and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310000, China.
| | - Ying Wang
- Institute of Immunization and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310000, China.
| | - Hui Liang
- Institute of Immunization and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310000, China.
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Venkateswaran M, Bogale B, Abu Khader K, Awwad T, Friberg IK, Ghanem B, Hijaz T, Mørkrid K, Frøen JF. Effective coverage of essential antenatal care interventions: A cross-sectional study of public primary healthcare clinics in the West Bank. PLoS One 2019; 14:e0212635. [PMID: 30794645 PMCID: PMC6386267 DOI: 10.1371/journal.pone.0212635] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/06/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The proportion of women attending four or more antenatal care (ANC) visits is widely used for monitoring, but provides limited information on quality of care. Effective coverage metrics, assessing if ANC interventions are completely delivered, can identify critical gaps in healthcare service delivery. We aimed to measure coverage of at least one screening and effective coverage of ANC interventions in the public health system in the West Bank, Palestine, and to explore associations between infrastructure-related and maternal sociodemographic variables and effective coverage. METHODS We used data from paper-based clinical records of 1369 pregnant women attending ANC in 17 primary healthcare clinics. Infrastructure-related variables were derived from a 2014 national inventory assessment of clinics. Sample size calculations were made to detect effective coverage ranging 40-60% with a 2-3% margin of error, clinics were selected by probability sampling. We calculated inverse probability weighted percentages of: effective coverage of appropriate number and timing of screenings of ANC interventions; and coverage of at least one screening. RESULTS Coverage of one screening and effective coverage of ANC interventions were notably different for screening for: hypertension (98% vs. 10%); fetal growth abnormalities (66% vs. 6%); anemia (93% vs. 14%); gestational diabetes (93% vs. 34%), and antenatal ultrasound (74% vs. 24%). Clinics with a laboratory and ultrasound generally performed better in terms of effective coverage, and maternal sociodemographic factors had no associations with effective coverage estimates. Only 13% of the women attended ANC visits according to the recommended national schedule, driving effective coverage down. CONCLUSION Indicators for ANC monitoring and their definitions can have important consequences for quantifying health system performance and identifying issues with care provision. To achieve more effective coverage in public primary care clinics in the West Bank, efforts should be made to improve care provision according to prescribed guidelines.
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Affiliation(s)
- Mahima Venkateswaran
- Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
| | - Binyam Bogale
- Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
| | - Khadija Abu Khader
- Palestinian National Institute of Public Health, World Health Organization, Ramallah, Palestine
| | - Tamara Awwad
- Palestinian National Institute of Public Health, World Health Organization, Ramallah, Palestine
| | - Ingrid K. Friberg
- Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Buthaina Ghanem
- Palestinian National Institute of Public Health, World Health Organization, Ramallah, Palestine
| | | | - Kjersti Mørkrid
- Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - J. Frederik Frøen
- Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
- * E-mail:
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Ruktanonchai CW, Nilsen K, Alegana VA, Bosco C, Ayiko R, Seven Kajeguka AC, Matthews Z, Tatem AJ. Temporal trends in spatial inequalities of maternal and newborn health services among four east African countries, 1999-2015. BMC Public Health 2018; 18:1339. [PMID: 30514269 PMCID: PMC6278077 DOI: 10.1186/s12889-018-6241-8] [Citation(s) in RCA: 18] [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] [Received: 05/01/2018] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa continues to account for the highest regional maternal mortality ratio (MMR) in the world, at just under 550 maternal deaths per 100,000 live births in 2015, compared to a global rate of 216 deaths. Spatial inequalities in access to life-saving maternal and newborn health (MNH) services persist within sub-Saharan Africa, however, with varied improvement over the past two decades. While previous research within the East African Community (EAC) region has examined utilisation of MNH care as an emergent property of geographic accessibility, no research has examined how these spatial inequalities have evolved over time at similar spatial scales. METHODS Here, we analysed temporal trends of spatial inequalities in utilisation of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) among four East African countries. Specifically, we used Bayesian spatial statistics to generate district-level estimates of these services for several time points using Demographic and Health Surveys data in Kenya, Tanzania, Rwanda, and Uganda. We examined temporal trends of both absolute and relative indices over time, including the absolute difference between estimates, as well as change in performance ratios of the best-to-worst performing districts per country. RESULTS Across all countries, we found the greatest spatial equality in ANC, while SBA and PNC tended to have greater spatial variability. In particular, Rwanda represented the only country to consistently increase coverage and reduce spatial inequalities across all services. Conversely, Tanzania had noticeable reductions in ANC coverage throughout most of the country, with some areas experiencing as much as a 55% reduction. Encouragingly, however, we found that performance gaps between districts have generally decreased or remained stably low across all countries, suggesting countries are making improvements to reduce spatial inequalities in these services. CONCLUSIONS We found that while the region is generally making progress in reducing spatial gaps across districts, improvement in PNC coverage has stagnated, and should be monitored closely over the coming decades. This study is the first to report temporal trends in district-level estimates in MNH services across the EAC region, and these findings establish an important baseline of evidence for the Sustainable Development Goal era.
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Affiliation(s)
- Corrine W. Ruktanonchai
- WorldPop, Geography and Environmental Science, University of Southampton, Southampton, UK
- Flowminder Foundation, Roslagsgatan 17, SE-11355 Stockholm, Sweden
| | - Kristine Nilsen
- WorldPop, Geography and Environmental Science, University of Southampton, Southampton, UK
- Flowminder Foundation, Roslagsgatan 17, SE-11355 Stockholm, Sweden
| | - Victor A. Alegana
- Population Health Theme, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Geography and Environmental Science, University of Southampton, Southampton, SO17 1BJ UK
| | - Claudio Bosco
- WorldPop, Geography and Environmental Science, University of Southampton, Southampton, UK
- Flowminder Foundation, Roslagsgatan 17, SE-11355 Stockholm, Sweden
| | - Rogers Ayiko
- Open Health Initiative, East African Community Secretariat, Arusha, Tanzania
| | - Andrew C. Seven Kajeguka
- EAC Integrated Health Programme (EIHP), Health Department, East African Community (EAC) Secretariat, Arusha, United Republic of Tanzania
| | - Zöe Matthews
- Division of Social Statistics and Demography & Centre for Global Health, Population, Poverty and Policy, University of Southampton, Southampton, UK
| | - Andrew J. Tatem
- WorldPop, Geography and Environmental Science, University of Southampton, Southampton, UK
- Flowminder Foundation, Roslagsgatan 17, SE-11355 Stockholm, Sweden
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Munos MK, Maiga A, Do M, Sika GL, Carter ED, Mosso R, Dosso A, Leyton A, Khan SM. Linking household survey and health facility data for effective coverage measures: a comparison of ecological and individual linking methods using the Multiple Indicator Cluster Survey in Côte d'Ivoire. J Glob Health 2018; 8:020803. [PMID: 30410743 PMCID: PMC6211616 DOI: 10.7189/jogh.08.020803] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Population-based measures of intervention coverage are used in low- and middle-income countries for program planning, prioritization, and evaluation. There is increased interest in effective coverage, which integrates information about service quality or health outcomes. Approaches proposed for quality-adjusted effective coverage include linking data on need and service contact from population-based surveys with data on service quality from health facility surveys. However, there is limited evidence about the validity of different linking methods for effective coverage estimation. Methods We collaborated with the 2016 Côte d'Ivoire Multiple Indicator Cluster Survey (MICS) to link data from a health provider assessment to care-seeking data collected by the MICS in the Savanes region of Côte d'Ivoire. The provider assessment was conducted in a census of public and non-public health facilities and pharmacies in Savanes in May-June 2016. We also included community health workers managing sick children who served the clusters sampled for the MICS. The provider assessment collected information on structural and process quality for antenatal care, delivery and immediate newborn care, postnatal care, and sick child care. We linked the MICS and provider data using exact-match and ecological linking methods, including aggregate linking and geolinking methods. We compared the results obtained from exact-match and ecological methods. Results We linked 731 of 786 care-seeking episodes (93%) from the MICS to a structural quality score for the provider named by the respondent. Effective coverage estimates computed using exact-match methods were 13%-63% lower than the care-seeking estimates from the MICS. Absolute differences between exact match and ecological linking methods were ±7 percentage points for all ecological methods. Incorporating adjustments for provider category and weighting by service-specific utilization into the ecological methods generally resulted in better agreement between ecological and exact match estimates. Conclusions Ecological linking may be a feasible and valid approach for estimating quality-adjusted effective coverage when a census of providers is used. Adjusting for provider type and caseload may improve agreement with exact match results. There remain methodological questions to be addressed to develop guidance on using linking methods for estimating quality-adjusted effective coverage, including the effect of facility sampling and time displacement.
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Affiliation(s)
- Melinda K Munos
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maiga
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mai Do
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, Tulane, New Orleans, Louisiana, USA
| | - Glebelho Lazare Sika
- Ecole Nationale Supérieure de Statistique et d'Economie Appliquée, Abidjan, Côte d'Ivoire
| | - Emily D Carter
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rosine Mosso
- Ecole Nationale Supérieure de Statistique et d'Economie Appliquée, Abidjan, Côte d'Ivoire
| | - Abdul Dosso
- Johns Hopkins Center for Communication Programs, Abidjan, Côte d'Ivoire
| | - Alejandra Leyton
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, Tulane, New Orleans, Louisiana, USA
| | - Shane M Khan
- Division of Data, Research and Policy, UNICEF, New York, New York, USA
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Jannati A, Sadeghi V, Imani A, Saadati M. Effective coverage as a new approach to health system performance assessment: a scoping review. BMC Health Serv Res 2018; 18:886. [PMID: 30470214 PMCID: PMC6251131 DOI: 10.1186/s12913-018-3692-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 11/07/2018] [Indexed: 11/29/2022] Open
Abstract
Background Delivering interventions is the main task of health systems whose accurate measurement is an essential input into tracking performance. Recently, the concept of effective coverage was introduced by World Health Organization to incorporate into health system performance assessment. The aim of present scoping review was mapping the key elements and steps of effective coverage assessment in practical efforts including kinds of interventions, criteria for selecting them and the need, use and quality estimation approaches and strategies of each intervention. Methods We conducted a scoping review of health system/program assessments which assessed effective coverage till May 2017. Seven databases were systematically searched with no time and language restriction through applying combined keyword of “effective coverage”. Results Eighteen studies contributed findings on monitoring effective coverage of health interventions and they all were included in the review. Only 4 contributed findings on health system and the others were related to specific intervention(s) assessment. The interventions monitored by effective coverage were mainly in child health, prenatal and antenatal care and delivery, and chronic conditions areas. Potential impact on the burden of disease, leading causes of mortality and morbidity, and high occurrence and prevalence rate were among the main intervention selection criteria. Availability of data was the critical prerequisite, especially, in all of the studies applied ex post approach in estimating effective coverage. Estimation based on a norm, self- reporting from surveys and biomarkers were the main strategies and methods of need, utilization and quality measurement, respectively. Conclusions More studies are needed to contribute to the ongoing improvement in the development of effective coverage concept and increasing practical efforts, especially through defining prospective approaches and strategies into estimation of composite measures based on the effective coverage framework. Also, further attention needs to be paid to quality measures of effective coverage in a manner that better conceptualizes and measures the connection between coverage rates and interventions’ effectiveness. At the administrative system level, more innovation is needed to develop data systems in order to enhance capacity of routine health service information. Electronic supplementary material The online version of this article (10.1186/s12913-018-3692-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ali Jannati
- Health Services Management, Iranian Center of Excellence in Health Management, Health Services Management Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahideh Sadeghi
- Health Services Management, Health Services Management Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, University Street, next to Shahid Madani hospital, Tabriz, 5165665811, Iran.
| | - Ali Imani
- Pharmacoeconomics and Pharmaceutical Management, Tabriz Health Services Management Research center, Health Economics Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Saadati
- Health Services Management, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Khatri RB, Karkee R. Social determinants of health affecting utilisation of routine maternity services in Nepal: a narrative review of the evidence. REPRODUCTIVE HEALTH MATTERS 2018; 26:32-46. [PMID: 30403932 DOI: 10.1080/09688080.2018.1535686] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Nepal has one of the highest maternal and neonatal mortality rates among low- and middle-income countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.
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Affiliation(s)
- Resham Bahadur Khatri
- a PhD Candidate, School of Public Health, Faculty of Medicine , The University of Queensland , Brisbane, Australia; Centers for Research and Development, Kathmandu , Nepal
| | - Rajendra Karkee
- b Associate Professor, School of Public Health and Community Medicine , BP Koirala Institute of Health Sciences , Dharan , Nepal
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Leslie HH, Zhou X, Spiegelman D, Kruk ME. Health system measurement: Harnessing machine learning to advance global health. PLoS One 2018; 13:e0204958. [PMID: 30289935 PMCID: PMC6173424 DOI: 10.1371/journal.pone.0204958] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/15/2018] [Indexed: 11/21/2022] Open
Abstract
Background Further improvements in population health in low- and middle-income countries demand high-quality care to address an increasingly complex burden of disease. Health facility surveys provide an important but costly source of information on readiness to provide care. To improve the efficiency of health system measurement, we applied unsupervised machine learning methods to assess the performance of the service readiness index (SRI) defined by the World Health Organization and compared it to empirically derived indices. Methods We drew data from nationally representative Service Provision Assessment surveys conducted in 10 countries between 2007 and 2015. We extracted 649 items in domains such as infrastructure, medication, and management to calculate an index using all available information and classified facilities into quintiles. We compared three approaches against the full item set: the SRI, a new index based on sequential backward selection, and an enriched SRI that added empirically selected items to the SRI. We evaluated index performance with a cross-validated kappa statistic comparing classification using the candidate index against the 649-item index. Results 9238 facilities were assessed. The 49-item SRI performed poorly against the index using all 649 items, with a kappa value of 0.35. New empirically derived indices with 50 and 100 items captured much more information, with cross-validated kappa statistics of 0.71 and 0.80, respectively. Items varied across the indices and in sensitivity analyses. A 100-item enriched SRI reliably captured the information from the full index: 83% of the facilities were classified into correct quintiles of service readiness based on the full index. Conclusion A facility readiness measure developed by global health experts performed poorly in capturing the totality of readiness information collected during facility surveys. Using a machine learning approach with sequential selection and cross-validation to identify the most informative items dramatically improved performance. Such approaches can make assessment of health facility readiness more efficient. Further improvements in measurement will require identification of external criteria—such as patient outcomes—to guide and validate measure development.
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Affiliation(s)
- Hannah H. Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Xin Zhou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Donna Spiegelman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Center on Methods for Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Bosire E, Mendenhall E, Omondi GB, Ndetei D. When Diabetes Confronts HIV: Biological Sub-citizenship at a Public Hospital in Nairobi, Kenya. Med Anthropol Q 2018; 32:574-592. [PMID: 30117196 DOI: 10.1111/maq.12476] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/14/2018] [Accepted: 08/02/2018] [Indexed: 12/31/2022]
Abstract
This article investigates how international donor policies cultivate a form of biological sub-citizenship for those with diabetes in Kenya. We interviewed 100 patients at a public hospital clinic in Nairobi, half with a diabetes diagnosis. We focus on three vignettes that illustrate how our study participants differentially perceived and experienced living with and seeking treatment and care for diabetes compared to other conditions, with a special focus on HIV. We argue that biological sub-citizenship, where those with HIV have consistent and comprehensive free medical care and those with diabetes must pay out-of-pocket for testing and treatment, impedes diabetes testing and treatment. Once diagnosed, many are then systematically excluded from the health care system due to their own inability to pay. We argue that the systematic exclusion from international donor money creates a form of biological sub-citizenship based on neoliberal economic policies that undermine other public health protections, such as universal primary health care.
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Affiliation(s)
- Edna Bosire
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Emily Mendenhall
- Science, Technology, and International Affairs Program, Walsh School of Foreign Service, Georgetown University, Washington, DC, USA
| | | | - David Ndetei
- Africa Mental Health Foundation, Nairobi, Kenya.,Department of Psychiatry, University of Nairobi, Nairobi, Kenya
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Koulidiati JL, De Allegri M, Souares A, Ouedraogo S, Hien H, Robyn PJ, Brenner S. Factors associated with effective coverage of child health services in Burkina Faso. Trop Med Int Health 2018; 23:1188-1199. [DOI: 10.1111/tmi.13140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - Aurelia Souares
- Institute of Public Health; Heidelberg University; Heidelberg Germany
| | | | - Hervé Hien
- Centre Muraz; Bobo-Dioulasso Burkina Faso
- Institut de recherche en science de la santé; Bobo-Dioulasso Burkina Faso
| | | | - Stephan Brenner
- Institute of Public Health; Heidelberg University; Heidelberg Germany
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Kukla M, McKay N, Rheingans R, Harman J, Schumacher J, Kotloff KL, Levine MM, Breiman R, Farag T, Walker D, Nasrin D, Omore R, O'Reilly C, Mintz E. The effect of costs on Kenyan households' demand for medical care: why time and distance matter. Health Policy Plan 2018; 32:1397-1406. [PMID: 29036378 DOI: 10.1093/heapol/czx120] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2017] [Indexed: 11/14/2022] Open
Abstract
In an environment of constrained resources, policymakers must identify solutions for financing and delivering health services that are efficient and sustainable. However, such solutions require that policymakers understand the complex interaction between household utilization patterns, factors influencing household medical decisions, and provider performance. This study examined whether and under what conditions out-of-pocket, transportation, and time costs influenced Kenyan households' choice of medical provider for childhood diarrhoeal illnesses. It compared these decisions with the actual cost and quality of those providers to assess strategies for increasing the utilization of high quality, low-cost primary care. This study analyzed nationally-representative survey data through several multinomial nested logit models. On average, time costs accounted for the greatest share of total costs. Households spent the most time and transportation costs utilizing public care, yet were more likely to incur catastrophic time and out-of-pocket costs seeking private care for their child's diarrhoeal illness. Out-of-pocket, transportation, and time costs influenced households' choice of provider, though demand was cost inelastic and households were most responsive to transportation costs. Poorer households were the most responsive to changes in all cost types and most likely to self-treat or utilize informal care. Many households utilized informal care that, relative to formal care, cost the same but was of worse quality-suggesting that such households were making poor medical decisions for their children. To achieve public policy objectives, such as financial risk protection for childhood illnesses and equitable access to primary care, policymakers could focus on three areas: (1) refine financing strategies for further reducing household out-of-pocket costs; (2) reduce or subsidize time and transportation costs for households seeking public and private care; and (3) increase transparency of costs and quality to improve household decisions.
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Affiliation(s)
- Matt Kukla
- Health Finance and Governance Project, Abt Associates Inc., Bethesda, MD, USA
| | - Niccie McKay
- Department of Health Services Research, Mgmt and Policy, University of Florida, FL, USA
| | - Richard Rheingans
- Department of Sustainable Development, Appalachian State University, Boone, NC, USA
| | - Jeff Harman
- Department of Behavioral Sciences and Social Medicine, Florida State University, FL, USA
| | - Jessica Schumacher
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Karen L Kotloff
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Myrone M Levine
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Robert Breiman
- Global Health Institute, Emory University, Atlanta, GA, USA
| | - Tamer Farag
- Institute of Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Damian Walker
- Data and Analytics, Bill and Melinda Gates Foundation, Seattle, WA, USA
| | - Dilruba Nasrin
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Richard Omore
- Centers of Disease Control and Prevention, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ciara O'Reilly
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - Eric Mintz
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
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Tama E, Molyneux S, Waweru E, Tsofa B, Chuma J, Barasa E. Examining the Implementation of the Free Maternity Services Policy in Kenya: A Mixed Methods Process Evaluation. Int J Health Policy Manag 2018; 7:603-613. [PMID: 29996580 PMCID: PMC6037504 DOI: 10.15171/ijhpm.2017.135] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/18/2017] [Indexed: 11/10/2022] Open
Abstract
Background: Kenya introduced a free maternity policy in 2013 to address the cost barrier associated with accessing maternal health services. We carried out a mixed methods process evaluation of the policy to examine the extent to which the policy had been implemented according to design, and positive experiences and challenges encountered during implementation.
Methods: We conducted a mixed methods study in 3 purposely selected counties in Kenya. Data were collected through in-depth interviews (IDIs) with policy-makers at the national level, health managers at the county level, and frontline staff at the health facility level (n=60), focus group discussions (FGDs) with community representatives (n=10), facility records, and document reviews. We analysed the data using a framework approach.
Results: Rapid implementation led to inadequate stakeholder engagement and confusion about the policy. While the policy was meant to cover antenatal visits, deliveries, and post-natal visits, in practice the policy only covered deliveries. While the policy led to a rapid increase in facility deliveries, this was not matched by an increase in health facility capacity and hence compromised quality of care. The policy led to an improvement in the level of revenues for facilities. However, in all three counties, reimbursements were not made on time. The policy did not have a system of verifying health facility reports on utilization of services.
Conclusion: The Kenyan Ministry of Health (MoH) should develop a formal policy on the free maternity services, and provide clear guidelines on its content and implementation arrangements, engage with and effectively communicate the policy to stakeholders, ensure timeliness of payment disbursement to healthcare facilities, and introduce a mechanism for verifying utilization reports prepared by healthcare providers. User fee removal policies such as free maternity programmes should be accompanied by supply side capacity strengthening.
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Affiliation(s)
- Eric Tama
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
| | | | - Evelyn Waweru
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Jane Chuma
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,The World Bank, Kenya Country Office, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Barasa E, Nguhiu P, McIntyre D. Measuring progress towards Sustainable Development Goal 3.8 on universal health coverage in Kenya. BMJ Glob Health 2018; 3:e000904. [PMID: 29989036 PMCID: PMC6035501 DOI: 10.1136/bmjgh-2018-000904] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 05/14/2018] [Accepted: 06/02/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The inclusion of universal health coverage (UHC) as a health-related Sustainable Development Goal has cemented its position as a key global health priority. We aimed to develop a summary measure of UHC for Kenya and track the country's progress between 2003 and 2013. METHODS We developed a summary index for UHC by computing the geometrical mean of indicators for the two dimensions of UHC, service coverage (SC) and financial risk protection (FRP). The SC indicator was computed as the geometrical mean of preventive and treatment indicators, while the financial protection indicator was computed as a geometrical mean of an indicator for the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments. We analysed data from three waves of two nationally representative household surveys. FINDINGS The weighted summary indicator for SC increased from 27.65% (27.13%-28.14%) in 2003 to 41.73% (41.34%-42.12%) in 2013, while the summary indicator for FRP reduced from 69.82% (69.11%-70.51%) in 2003 to 63.78% (63.55%-63.82%) in 2013. Inequities were observed in both these indicators. The weighted summary measure of UHC increased from 43.94% (95% CI 43.48% to 44.38%) in 2003 to 51.55% (95% CI 51.29% to 51.82%) in 2013. CONCLUSION Significant gaps exist in Kenya's quest to achieve UHC. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both, rather than on only either, of the dimensions of UHC.
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Affiliation(s)
- Edwine Barasa
- Health Economics Research Unit, Centre for Geographic Medicine Research Coast, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Peter Nguhiu
- Health Economics Research Unit, Centre for Geographic Medicine Research Coast, Nairobi, Kenya
| | - Di McIntyre
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, South Africa
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Willey B, Waiswa P, Kajjo D, Munos M, Akuze J, Allen E, Marchant T. Linking data sources for measurement of effective coverage in maternal and newborn health: what do we learn from individual- vs ecological-linking methods? J Glob Health 2018. [DOI: 10.7189/jogh.06.0207028.010601] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Koulidiati JL, Nesbitt RC, Ouedraogo N, Hien H, Robyn PJ, Compaoré P, Souares A, Brenner S. Measuring effective coverage of curative child health services in rural Burkina Faso: a cross-sectional study. BMJ Open 2018; 8:e020423. [PMID: 29858415 PMCID: PMC5988102 DOI: 10.1136/bmjopen-2017-020423] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/26/2018] [Accepted: 03/05/2018] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To estimate both crude and effective curative health services coverage provided by rural health facilities to under 5-year-old (U5YO) children in Burkina Faso. METHODS We surveyed 1298 child health providers and 1681 clinical cases across 494 primary-level health facilities, as well as 12 497 U5YO children across 7347households in the facilities' catchment areas. Facilities were scored based on a set of indicators along three quality-of-care dimensions: management of common childhood diseases, management of severe childhood diseases and general service readiness. Linking service quality to service utilisation, we estimated both crude and effective coverage of U5YO children by these selected curative services. RESULTS Measured performance quality among facilities was generally low with only 12.7% of facilities surveyed reaching our definition of high and 57.1% our definition of intermediate quality of care. The crude coverage was 69.5% while the effective coverages indicated that 5.3% and 44.6% of children reporting an illness episode received services of only high or high and intermediate quality, respectively. CONCLUSION Our study showed that the quality of U5YO child health services provided by primary-level health facilities in Burkina Faso was low, resulting in relatively ineffective population coverage. Poor adherence to clinical treatment guidelines combined with the lack of equipment and qualified clinical staff that performed U5YO consultations seemed to be contributors to the gap between crude and effective coverage.
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Affiliation(s)
| | - Robin C Nesbitt
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
| | - Nobila Ouedraogo
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
| | - Hervé Hien
- Centre Muraz, Bobo-Dioulasso, Burkina Faso
- Institut de recherche en science de la santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | | | | | - Aurélia Souares
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
| | - Stephan Brenner
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
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48
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Willey B, Waiswa P, Kajjo D, Munos M, Akuze J, Allen E, Marchant T. Linking data sources for measurement of effective coverage in maternal and newborn health: what do we learn from individual- vs ecological-linking methods? J Glob Health 2018; 8:010601. [PMID: 29497508 PMCID: PMC5823029 DOI: 10.7189/jogh.08.010601] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background Improving maternal and newborn health requires improvements in the quality of facility-based care. This is challenging to measure: routine data may be unreliable; respondents in population surveys may be unable to accurately report on quality indicators; and facility assessments lack population level denominators. We explored methods for linking access to skilled birth attendance (SBA) from household surveys to data on provision of care from facility surveys with the aim of estimating population level effective coverage reflecting access to quality care. Methods We used data from Mayuge District, Uganda. Data from household surveys on access to SBA were linked to health facility assessment census data on readiness to provide basic emergency obstetric and newborn care (BEmONC) in the same district. One individual- and two ecological-linking methods were applied. All methods used household survey reports on where care at birth was accessed. The individual-linking method linked this to data about facility readiness from the specific facility where each woman delivered. The first ecological-linking approach used a district-wide mean estimate of facility readiness. The second used an estimate of facility readiness adjusted by level of health facility accessed. Absolute differences between estimates derived from the different linking methods were calculated, and agreement examined using Lin's concordance correlation coefficient. Results A total of 1177 women resident in Mayuge reported a birth during 2012-13. Of these, 664 took place in facilities within Mayuge, and were eligible for linking to the census of the district's 38 facilities. 55% were assisted by a SBA in a facility. Using the individual-linking method, effective coverage of births that took place with an SBA in a facility ready to provide BEmONC was just 10% (95% confidence interval CI 3-17). The absolute difference between the individual- and ecological-level linking method adjusting for facility level was one percentage point (11%), and tests suggested good agreement. The ecological method using the district-wide estimate demonstrated poor agreement. Conclusions The proportion of women accessing appropriately equipped facilities for care at birth is far lower than the coverage of facility delivery. To realise the life-saving potential of health services, countries need evidence to inform actions that address gaps in the provision of quality care. Linking household and facility-based information provides a simple but innovative method for estimating quality of care at the population level. These encouraging findings suggest that linking data sets can result in meaningful evidence even when the exact location of care seeking is not known.
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Affiliation(s)
- Barbara Willey
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Waiswa
- Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Darious Kajjo
- Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Melinda Munos
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joseph Akuze
- Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Elizabeth Allen
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Tanya Marchant
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Munge K, Mulupi S, Barasa EW, Chuma J. A Critical Analysis of Purchasing Arrangements in Kenya: The Case of the National Hospital Insurance Fund. Int J Health Policy Manag 2018. [PMID: 29524953 PMCID: PMC5890069 DOI: 10.15171/ijhpm.2017.81] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of
health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries
(LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the
National Hospital Insurance Fund (NHIF) as a case study.
Methods: We applied a principal-agent relationship framework, which identifies three pairs of principal-agent
relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within
them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through
document reviews (statutes, policy and regulatory documents) and in-depth interviews (n=62) with key informants
including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers.
Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed
using a thematic framework approach.
Results: The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear
accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed
over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting,
monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical
distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing
needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist,
they do not always function appropriately and awareness of these channels to the beneficiaries is limited.
Conclusion: Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically,
there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the
multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity
that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal
health coverage (UHC).
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Affiliation(s)
- Kenneth Munge
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Stephen Mulupi
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine W Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jane Chuma
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,Kenya Country Office, The World Bank, Nairobi, Kenya
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50
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Leslie HH, Sun Z, Kruk ME. Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries. PLoS Med 2017; 14:e1002464. [PMID: 29232377 PMCID: PMC5726617 DOI: 10.1371/journal.pmed.1002464] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/25/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND It is increasingly apparent that access to healthcare without adequate quality of care is insufficient to improve population health outcomes. We assess whether the most commonly measured attribute of health facilities in low- and middle-income countries (LMICs)-the structural inputs to care-predicts the clinical quality of care provided to patients. METHODS AND FINDINGS Service Provision Assessments are nationally representative health facility surveys conducted by the Demographic and Health Survey Program with support from the US Agency for International Development. These surveys assess health system capacity in LMICs. We drew data from assessments conducted in 8 countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda. The surveys included an audit of facility infrastructure and direct observation of family planning, antenatal care (ANC), sick-child care, and (in 2 countries) labor and delivery. To measure structural inputs, we constructed indices that measured World Health Organization-recommended amenities, equipment, and medications in each service. For clinical quality, we used data from direct observations of care to calculate providers' adherence to evidence-based care guidelines. We assessed the correlation between these metrics and used spline models to test for the presence of a minimum input threshold associated with good clinical quality. Inclusion criteria were met by 32,531 observations of care in 4,354 facilities. Facilities demonstrated moderate levels of infrastructure, ranging from 0.63 of 1 in sick-child care to 0.75 of 1 for family planning on average. Adherence to evidence-based guidelines was low, with an average of 37% adherence in sick-child care, 46% in family planning, 60% in labor and delivery, and 61% in ANC. Correlation between infrastructure and evidence-based care was low (median 0.20, range from -0.03 for family planning in Senegal to 0.40 for ANC in Tanzania). Facilities with similar infrastructure scores delivered care of widely varying quality in each service. We did not detect a minimum level of infrastructure that was reliably associated with higher quality of care delivered in any service. These findings rely on cross-sectional data, preventing assessment of relationships between structural inputs and clinical quality over time; measurement error may attenuate the estimated associations. CONCLUSION Inputs to care are poorly correlated with provision of evidence-based care in these 4 clinical services. Healthcare workers in well-equipped facilities often provided poor care and vice versa. While it is important to have strong infrastructure, it should not be used as a measure of quality. Insight into health system quality requires measurement of processes and outcomes of care.
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Affiliation(s)
- Hannah H. Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Zeye Sun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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