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Arsenault C, Wright K, Taddele T, Tadele A, Derseh Mebratie A, Tiruneh Tiyare F, Kosgei RJ, Nzinga J, Holt B, Mugenya I, Clarke-Deelder E, Nega A, Prabhakaran D, Mohan S, Mfeka-Nkabinde NG, Mthethwa L, Haile Mariam D, Molla G, Getachew T, Jarhyan P, Chaudhry M, Kassa M, Kruk ME. The maternal and newborn health eCohort to track longitudinal care quality: study protocol and survey development. Glob Health Action 2024; 17:2392352. [PMID: 39163134 PMCID: PMC11338195 DOI: 10.1080/16549716.2024.2392352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Abstract
The MNH eCohort was developed to fill gaps in maternal and newborn health (MNH) care quality measurement. In this paper, we describe the survey development process, recruitment strategy, data collection procedures, survey content and plans for analysis of the data generated by the study. We also compare the survey content to that of existing multi-country tools on MNH care quality. The eCohort is a longitudinal mixed-mode (in-person and phone) survey that will recruit women in health facilities at their first antenatal care (ANC) visit. Women will be followed via phone survey until 10-12 weeks postpartum. User-reported information will be complemented with data from physical health assessments at baseline and endline, extraction from MNH cards, and a brief facility survey. The final MNH eCohort instrument is centered around six key domains of high-quality health systems including competent care (content of ANC, delivery, and postnatal care for the mother and newborn), competent systems (prevention and detection, timely care, continuity, integration), user experience, health outcomes, confidence in the health system, and economic outcomes. The eCohort combines the maternal and newborn experience and, due to its longitudinal nature, will allow for quality assessment according to specific risks that evolve throughout the pregnancy and postpartum period. Detailed information on medical and obstetric history and current health status of respondents and newborns will allow us to determine whether women and newborns at risk are receiving needed care. The MNH eCohort will answer novel questions to guide health system improvements and to fill data gaps in implementing countries.
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Affiliation(s)
- Catherine Arsenault
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Katherine Wright
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Tefera Taddele
- Health System Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ashenif Tadele
- Health System Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Anagaw Derseh Mebratie
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Firew Tiruneh Tiyare
- Health System Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Rose J. Kosgei
- Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya
| | - Jacinta Nzinga
- Health Economics Research Unit, KEMRI Wellcome Trust Research Program, Nairobi, Kenya
| | - Bethany Holt
- Blavatnik Institute of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Irene Mugenya
- Health Economics Research Unit, KEMRI Wellcome Trust Research Program, Nairobi, Kenya
| | - Emma Clarke-Deelder
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Allschwil, Switzerland
| | - Adiam Nega
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, Gurgaon, India
- Centre for Chronic Disease Control, New Delhi, India
| | | | | | - Londiwe Mthethwa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Damen Haile Mariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gebeyaw Molla
- Health System Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Theodros Getachew
- Health System Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | | | - Munir Kassa
- Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Yeboah E, Lohmann J, Koulidiati JL, Kuunibe N, Kyei NNA, Hamadou S, Ridde V, Danquah I, Brenner S, De Allegri M. Quality of nutritional status assessment and its relationship with the effect of rainfall on childhood stunting: a cross-sectional study in rural Burkina Faso. Public Health 2024; 234:91-97. [PMID: 38970856 DOI: 10.1016/j.puhe.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVES In Burkina Faso, one in every four children under 5 years is stunted. Climate change will exacerbate childhood stunting. Strengthening the health system, particularly the quality of nutrition care at primary health facilities, can minimise the adverse climate effect on stunting. Thus, we examined the quality of nutritional status assessment (QoNA) during curative childcare services in primary health facilities in rural Burkina Faso and its relationship with rainfall-induced childhood stunting. STUDY DESIGN We conducted a cross-sectional analysis using anthropometric, rainfall, and clinical observation data. METHODS Our dependent variable was the height-for-age z-score (HAZ) of children under 2 years. Our focal climatic measure was mean rainfall deviation (MRD), calculated as the mean of the difference between 30-year monthly household-level rainfall means and the corresponding months for each child from conception to data collection. QoNA was based on the weight, height, general paleness and oedema assessment. We used a mixed-effect multilevel model and analysed heterogeneity by sex and socio-economic status. RESULTS Among 5027 young (3-23 months) children (mean age 12 ± 6 months), 21% were stunted (HAZ ≤ -2). The mean MRD was 11 ± 4 mm, and the mean QoNA was 2.86 ± 0.99. The proportion of children in low, medium, and high QoNA areas was 10%, 54%, and 36%, respectively. HAZ showed a negative correlation with MRD. Higher QoNA lowered the negative effect of MRD on HAZ (β = 0.017, P = 0.003, confidence interval = [0.006, 0.029]). Males and children from poor households benefited less from the moderating effect of QoNA. CONCLUSION Improving the quality of nutrition assessments can supplement existing efforts to reduce the adverse effects of climate change on children's nutritional well-being.
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Affiliation(s)
- Edmund Yeboah
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
| | - Julia Lohmann
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany; Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - J-L Koulidiati
- Institut Supérieur des Sciences de la Santé, Université Nazi Boni, 01 BP 1091, Bobo Dioulasso, Burkina Faso
| | - Naasegnibe Kuunibe
- Department of Economics, Faculty of Social Science and Arts, Simon Diedong Dombo University of Business and Integrated Development Studies, P O Box WA64, Wa, Ghana
| | - N N A Kyei
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany; Institute of Public Health, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Unversität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany; Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, P. O. Box 60 12 03, 14412, Potsdam, Germany
| | - S Hamadou
- The World Bank, 1818 H Street, NW Washington, DC, 20433, USA
| | - V Ridde
- Université Paris Cité, IRD, Inserm, Ceped Paris, France
| | - I Danquah
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - S Brenner
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - M De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
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García PJ, Leslie H, Medina-Ranilla J, Espinoza-Pajuelo L, Guglielmino M, Roberti J, Mazzoni A, García-Elorrio E. The QuEST LAC network uses data to promote evidence-based policies for health in Latin America. Nat Med 2024; 30:1811-1812. [PMID: 38862715 DOI: 10.1038/s41591-024-03029-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Affiliation(s)
- Patricia J García
- Faculty of Public Health and Administration, Epidemiology Department, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Hannah Leslie
- Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jesús Medina-Ranilla
- Faculty of Public Health and Administration, Epidemiology Department, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Laura Espinoza-Pajuelo
- Faculty of Public Health and Administration, Epidemiology Department, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marina Guglielmino
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Javier Roberti
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET) - Centre for Research in Epidemiology and Public Health (CIESP), Buenos Aires, Argentina
| | - Agustina Mazzoni
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Ezequiel García-Elorrio
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET) - Centre for Research in Epidemiology and Public Health (CIESP), Buenos Aires, Argentina
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Habte A, Hailegebreal S, Simegn AE. Predictors of maternal health services uptake in West African region: a multilevel multinomial regression analysis of demographic health survey reports. Reprod Health 2024; 21:45. [PMID: 38582831 PMCID: PMC10999082 DOI: 10.1186/s12978-024-01782-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/03/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Pursuant to studies, receiving the three key maternal health services (Antenatal Care, Skilled Delivery Service, and Postnatal Care) in a continuum could prevent 71% of global maternal deaths. Despite the Western African region being known for its high maternal death and poor access to maternal health services, there is a dearth of studies that delve into the spectrum of maternal health services uptake. Hence, this study aimed to assess the level and predictors of partial and adequate utilization of health services in a single analytical model using the most recent Demographic and Health Survey (DHS) data (2013-2021). METHODS This study was based on the appended women's (IR) file of twelve West African countries. STATA software version 16 was used to analyze a weighted sample of 89,504 women aged 15-49 years. A composite index of maternal health service utilization has been created by combining three key health services and categorizing them into 'no', 'partial', or 'adequate' use. A multilevel multivariable multinomial logistic regression analysis was carried out to examine the effects of each predictor on the level of service utilization. The degree of association was reported using the adjusted relative risk ratio (aRRR) with a corresponding 95% confidence interval, and statistical significance was declared at p < 0.05. RESULTS 66.4% (95% CI: 64.9, 67.7) and 23.8% (95% CI: 23.3, 24.2) of women used maternal health services partially and adequately, respectively. Togo has the highest proportion of women getting adequate health care in the region, at 56.7%, while Nigeria has the lowest proportion, at 11%. Maternal education, residence, wealth index, parity, media exposure (to radio and television), enrolment in health insurance schemes, attitude towards wife beating, and autonomy in decision-making were identified as significant predictors of partial and adequate maternal health service uptake. CONCLUSION The uptake of adequate maternal health services in the region was found to be low. Stakeholders should plan for and implement interventions that increase women's autonomy. Program planners and healthcare providers should give due emphasis to those women with no formal education and from low-income families. The government and the private sectors need to collaborate to improve media access and increase public enrolment in health insurance schemes.
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Affiliation(s)
- Aklilu Habte
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia.
| | - Samuel Hailegebreal
- College of Medicine and Health Sciences, School of Public Health, Department of Health Informatics, Wachemo University, Hosaena, Ethiopia
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Kruk ME, Lewis TP. Introduction to The Lancet Global Health's Series on the People's Voice Survey on Health System Performance. Lancet Glob Health 2024; 12:e14-e15. [PMID: 38096886 DOI: 10.1016/s2214-109x(23)00512-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Margaret E Kruk
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA 02115, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA 02115, USA
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Njuguna C, Tola HH, Maina BN, Magambo KN, Phoebe N, Tibananuka E, Turyashemererwa FM, Rubangakene M, Richard K, Opong G, Richard S, Opesen C, Mateeba T, Muyingo E, George U, Namukose S, Woldemariam YT. Essential health services delivery and quality improvement actions under drought and food insecurity emergency in north-east Uganda. BMC Health Serv Res 2023; 23:1387. [PMID: 38082433 PMCID: PMC10714455 DOI: 10.1186/s12913-023-10377-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Essential health services can be disrupted due to several naturally occurring public health emergencies such as drought, flood, earthquake and outbreak of infectious diseases. However, little evidence exists on the status of essential health services delivery under the effect of drought and food insecurity. North-east Uganda is severely affected by prolonged drought that significantly affected the livelihood of the residents. Therefore, we aimed to determine the current status of essential health services and quality improvement (QI) actions in health facilities in north-east Uganda. METHODS We used a descriptive cross-sectional study design to assess the availability of essential health service and quality improvement activities in drought and food insecurity affected districts of north-east Uganda. We included a total of 150 health facilities from 15 districts with proportionated multistage sampling method. We interviewed health facilities' managers and services focal persons using structured questionnaire and observation checklist. We used a descriptive statistic to analyze the data with SPSS version 22. RESULTS A few health facilities (8.7%) had mental health specialist. There was also lack of capacity building training on essential health services. Considerable proportion of health facilities had no non-communicable diseases (38.3%), mental health (47.0%), and basic emergency obstetric care (40.3%) services. Stock out of essential medicines were observed in 20% of health facilities. There was lack of supportive supervision, and poor documentation of QI activities. CONCLUSION Essential health service and QI were suboptimal in drought and food insecure emergency affected districts. Human resource deployment (especially mental health specialist), provision of capacity building training, improving non-communicable diseases, mental health and basic emergency obstetric care services are required to improve availability of essential health services. Supporting supply chain management to minimize stock out of medicines, and promoting QI activities are also vital to assure quality of health service in drought and food insecurity affected districts in north-Eastern Uganda.
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Affiliation(s)
- Charles Njuguna
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda.
| | - Habteyes Hailu Tola
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Benson Ngugi Maina
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Kwikiriza Nicholas Magambo
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Nabunya Phoebe
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Evelyne Tibananuka
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Florence M Turyashemererwa
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Moses Rubangakene
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Kisubika Richard
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - George Opong
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Ssekitoleko Richard
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Chris Opesen
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Tim Mateeba
- Ministry of Health of Uganda, Kampala, Uganda
| | | | | | | | - Yonas Tegegn Woldemariam
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
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Medina-Ranilla J, Espinoza-Pajuelo L, Mazzoni A, Roberti J, García-Elorrio E, Leslie HH, García PJ. A systematic review of population and patient perspectives and experiences as measured in Latin American and Caribbean surveys. Health Policy Plan 2023; 38:1225-1241. [PMID: 37803966 DOI: 10.1093/heapol/czad083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/20/2023] [Accepted: 09/11/2023] [Indexed: 10/08/2023] Open
Abstract
High-quality health systems must provide accessible, people-centred care to both improve health and maintain population trust in health services. Furthermore, accurate measurement of population perspectives is vital to hold health systems accountable and to inform improvement efforts. To describe the current state of such measures in Latin America and the Caribbean (LAC), we conducted a systematic review of facility and population-based assessments that included patient-reported experience and satisfaction measures. Five databases were searched for publications on quantitative surveys assessing healthcare quality in Spanish- or Portuguese-speaking LAC countries, focusing on the domains of processes of care and quality impacts. We included articles published since 2011 with a national sampling frame or inclusion of multiple subnational regions. We tabulated and described these articles, identifying, classifying and summarizing the items used to assess healthcare quality into the domains mentioned earlier. Of the 5584 publications reviewed, 58 articles met our inclusion criteria. Most studies were cross-sectional (95%), assessed all levels of healthcare (57%) and were secondary analyses of existing surveys (86%). The articles yielded 33 unique surveys spanning 12 LAC countries; only eight of them are regularly administered surveys. The most common quality domains assessed were satisfaction (in 33 out of 58 articles, 57%), evidence-based/effective care (34%), waiting times (33%), clear communication (33%) and ease of use (31%). Items and reported ratings varied widely among instruments used, time points and geographical settings. Assessment of patient-reported quality measures through population- and facility-based surveys is present but heterogeneous in LAC countries. Satisfaction was measured frequently, although its use in accountability or informing quality improvement is limited. Measurement of healthcare quality in LAC needs to be more systematic, regular, comprehensive and to be led collaboratively by researchers, governments and policymakers to enable comparison of results across countries and to effectively inform policy implementation.
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Affiliation(s)
- Jesús Medina-Ranilla
- School of Public Health and Administration, Epidemiology, STD and HIV Unit, Cayetano Heredia University (UPCH), Honorio Delgado Av. 430, San Martín de Porres, Lima 150135, Peru
| | - Laura Espinoza-Pajuelo
- School of Public Health and Administration, Epidemiology, STD and HIV Unit, Cayetano Heredia University (UPCH), Honorio Delgado Av. 430, San Martín de Porres, Lima 150135, Peru
| | - Agustina Mazzoni
- Health Care Quality and Patient Safety Department, Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires C1414CPV, Argentina
| | - Javier Roberti
- Health Care Quality and Patient Safety Department, Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires C1414CPV, Argentina
| | - Ezequiel García-Elorrio
- Health Care Quality and Patient Safety Department, Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires C1414CPV, Argentina
| | - Hannah Hogan Leslie
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th St., Floor 4, San Francisco, CA 94143, United States
| | - Patricia Jannet García
- School of Public Health and Administration, Epidemiology, STD and HIV Unit, Cayetano Heredia University (UPCH), Honorio Delgado Av. 430, San Martín de Porres, Lima 150135, Peru
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Sheffel A, Carter E, Zeger S, Munos MK. Association between antenatal care facility readiness and provision of care at the client level and facility level in five low- and middle-income countries. BMC Health Serv Res 2023; 23:1109. [PMID: 37848885 PMCID: PMC10583346 DOI: 10.1186/s12913-023-10106-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level. METHODS To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels. RESULTS Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect. CONCLUSIONS The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures.
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Affiliation(s)
- Ashley Sheffel
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205-2103 USA
| | - Emily Carter
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205-2103 USA
| | - Scott Zeger
- Departments of Biostatistics and International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205-2103 USA
| | - Melinda K. Munos
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205-2103 USA
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Shastry V, Morse SM. The gendered implications of energy gaps in health care: A comparative analysis of Haiti, Senegal, and the Democratic Republic of Congo. Health Care Women Int 2023; 44:1050-1072. [PMID: 34637687 DOI: 10.1080/07399332.2021.1964503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
Delivering quality primary health care requires reliable energy access. In rural health facilities, electricity is often unreliable or absent. Low energy access has a gendered impact, affecting the ability of mothers to experience safe childbirth, for which basic lighting and sterilization are essential. Moreover, low energy access acts as a barrier to attract and retain female medical staff, who constitute women-predominated nursing and midwifery cadres that are critical for providing care to women. Using quantitative facility-level data, we explore the intersection of energy, health care, and gender in Haiti, Senegal, and the Democratic Republic of the Congo.
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Affiliation(s)
- Vivek Shastry
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, USA
| | - Sophie M Morse
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, USA
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Wang W, Zhang J, Loban K, Wei X. High performing primary health care organizations from patient perspective: a qualitative study in China. Glob Health Res Policy 2023; 8:31. [PMID: 37544999 PMCID: PMC10405398 DOI: 10.1186/s41256-023-00315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND There is a global call to build people-centred primary health care (PHC) systems. Previous evidence suggests that without organization-level reform efforts, the full potential of policy reforms may be limited. This study aimed to generate a profile of high performing PHC organizations from the perspective of patients. METHODS We conducted semi-structured interviews with 58 PHC users from six provinces (Shandong, Zhejiang, Shaanxi, Henan, Shanxi, Heilongjiang) in China using purposive and snowball sampling techniques. Transcription was completed by trained research assistants through listening to the recordings of the interviews and summarizing them in English by 30-s segments to generate the narrative summary. Informed by the Classification System of PHC Organizational Attributes, thematic analysis aimed to identify domains and attributes of high performing PHC organizations. RESULTS A profile of a high performing PHC organization with five domains and 14 attributes was generated. The five domains included: (1) organizational resources including medical equipment, human and information resource; (2) service provision and clinical practice including practice scope, internal integration and external integration; (3) general features including location, environment and ownership; (4) quality and cost; and (5) organizational structure including continuous learning mechanism, administrative structure and governance. CONCLUSIONS A five-domain profile of high performing PHC organizations from the perspective of Chinese PHC users was generated. Organizational resources, service delivery and clinical practices were most valued by the participants. Meanwhile, the participants also had strong expectation of geographical accessibility, high quality of care as well as efficient organizational structure. These organizational elements should be reflected in further reform efforts in order to build high performing PHC organizations.
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Affiliation(s)
- Wenhua Wang
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, People's Republic of China.
| | - Jinnan Zhang
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Katya Loban
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Ikeda S, Shibanuma A, Pokharel A, Silwal RC, Jimba M. Improving the quality of maternal and newborn healthcare at the district level: Addressing newborn deaths in Nepal. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002101. [PMID: 37531345 PMCID: PMC10395984 DOI: 10.1371/journal.pgph.0002101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Abstract
Maternal and newborn care quality can be measured in three dimensions (Dimensions 1: care provision, 2: care experience, and 3: human and physical resources); however, little is known about which dimensions are associated with newborn and perinatal deaths. We examined the association between care quality and newborn and perinatal deaths in Nepal. This study incorporated secondary data from Nepal Service Provision Assessments (NSPA) 2015 (623 delivery facilities, facility inventory survey; 1,509 women, ANC clients interviews; 1,544 women, ANC observation) and Nepal Demographic and Health Surveys (NDHS) 2016 (5,038 women who reported having given birth in the five years preceding data collection). The outcome variables were newborn and perinatal deaths derived from the NDHS. The exposure variables were district-level maternal and newborn care quality scores calculated from the NSPA data. Covariates were women's sociodemographic, health, and obstetric characteristics. We applied the administrative boundary method to link these two surveys. We conducted binary logistic regression analyses to examine the association between care quality and newborn/perinatal deaths. In Dimension 1, higher mean and maximum quality scores at the district level were associated with a lower number of newborn deaths (mean: odds ratio [OR] = 0.04, 95% confidence interval [CI]: 0.00-0.76; max: OR = 0.09, 95% CI: 0.01-0.58), but not with perinatal deaths. In Dimensions 2 and 3, the quality score was not significantly associated with newborn deaths and perinatal. Enhancing the quality of care provision at its average and highest levels in each district may contribute to the reduction of newborn deaths, but not perinatal death. Health administrators should assess the quality of care at the administrative division level and focus on enhancing both average and maximum care quality of health facilities in each region in the care provision dimension.
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Affiliation(s)
- Subaru Ikeda
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Akira Shibanuma
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Alpha Pokharel
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Ram Chandra Silwal
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Masamine Jimba
- Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
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Han D, Clarke-Deelder E, Miller N, Opondo K, Burke T, Oguttu M, McConnell M, Cohen J. Health care provider decision-making and the quality of maternity care: An analysis of postpartum care in Kenyan hospitals. Soc Sci Med 2023; 331:116071. [PMID: 37450989 PMCID: PMC10410252 DOI: 10.1016/j.socscimed.2023.116071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/17/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care.
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Affiliation(s)
- Dan Han
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore; Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology and Public Health, Swiss TPH and University of Basel, Basel, Switzerland
| | - Nora Miller
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Kennedy Opondo
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Kisumu Medical and Education Trust, Kisumu, Kenya
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jessica Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Lewis TP, McConnell M, Aryal A, Irimu G, Mehata S, Mrisho M, Kruk ME. Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysis. Lancet Glob Health 2023; 11:e862-e870. [PMID: 37202022 DOI: 10.1016/s2214-109x(23)00163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Primary care is of insufficient quality in many low-income and middle-income countries. Some health facilities perform better than others despite operating in similar contexts, although the factors that characterise best performance are not well known. Existing best-performance analyses are concentrated in high-income countries and focus on hospitals. We used the positive deviance approach to identify the factors that differentiate best from worst primary care performance among health facilities across six low-resource health systems. METHODS This positive deviance analysis used nationally representative samples of public and private health facilities from Service Provision Assessments of the Democratic Republic of the Congo, Haiti, Malawi, Nepal, Senegal, and Tanzania. Data were collected starting June 11, 2013, in Malawi and ending Feb 28, 2020, in Senegal. We assessed facility performance through completion of the Good Medical Practice Index (GMPI) of essential clinical actions (eg, taking a thorough history, conducting an adequate physical examination) according to clinical guidelines and measured with direct observations of care. We identified hospitals and clinics in the top decile of performance (defined as best performers) and conducted a quantitative, cross-national positive deviance analysis to compare them with facilities performing below the median (defined as worst performers) and identify facility-level factors that explain the gap between best and worst performance. FINDINGS We identified 132 best-performing and 664 worst-performing hospitals, and 355 best-performing and 1778 worst-performing clinics based on clinical performance across countries. The mean GMPI score was 0·81 (SD 0·07) for the best-performing hospitals and 0·44 (0·09) for the worst-performing hospitals. Among clinics, mean GMPI scores were 0·75 (0·07) for the best performers and 0·34 (0·10) for the worst performers. High-quality governance, management, and community engagement were associated with best performance compared with worst performance. Private facilities out-performed government-owned hospitals and clinics. INTERPRETATION Our findings suggest that best-performing health facilities are characterised by good management and leaders who can engage staff and community members. Governments should look to best performers to identify scalable practices and conditions for success that can improve primary care quality overall and decrease quality gaps between health facilities. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Todd P Lewis
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Margaret McConnell
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Amit Aryal
- Swiss TPH, University of Basel, Basel, Switzerland
| | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Suresh Mehata
- Policy, Planning and Public Health Division, Ministry of Health, Biratnagar, Nepal
| | - Mwifadhi Mrisho
- Department of Health Systems, Impact Evaluation, and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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Appel I, Lohmann J, De Allegri M, Koulidiati JL, Somda S, Robyn PJ, Badolo H, Brenner S. Improving the readiness and clinical quality of antenatal care - findings from a quasi-experimental evaluation of a performance-based financing scheme in Burkina Faso. BMC Pregnancy Childbirth 2023; 23:352. [PMID: 37189035 DOI: 10.1186/s12884-023-05573-x] [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: 06/19/2022] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND While maternal mortality has declined globally, it remains highest in low-income countries. High-quality antenatal care (ANC) can prevent or decrease pregnancy-related complications for mothers and newborns. The implementation of performance-based financing (PBF) schemes in Sub-Saharan Africa to improve primary healthcare provision commonly includes financial indicators linked to ANC service quality indicators. In this study, we examine changes in ANC provision produced by the introduction of a PBF scheme in rural Burkina Faso. METHODS This study followed a quasi-experimental design with two data collection points comparing effects on ANC service quality between primary health facilities across intervention and control districts based on difference-in-differences estimates. Performance scores were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision related to screening and prevention pertaining to first and follow-up ANC visits. RESULTS We found a statistically significant increase in performance scores by 10 percent-points in facilities' readiness to provide ANC services. The clinical care provided to different ANC client groups scored generally low, especially with respect to preventive care measures, we failed to observe any substantial changes in the clinical provision of ANC care attributable to the PBF. CONCLUSION The observed effect pattern reflects the incentive structure implemented by the scheme, with a stronger focus on structural elements compared with clinical aspects of care. This limited the scheme's overall potential to improve ANC provision at the client level after the observed three-year implementation period. To improve both facility readiness and health worker performance, stronger incentives are needed to increase adherence to clinical standards and patient care outcomes.
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Affiliation(s)
- Inke Appel
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany.
- Department of Gynecology and Obstetrics, Otto-Von-Guericke University, Magdeburg, Germany.
| | - Julia Lohmann
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
- Institut Supérieur Des Sciences de La Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Serge Somda
- Centre Muraz, Institut National de Santé Publique (INSP), Bobo-Dioulasso, Burkina Faso
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, World Bank, D.C., Washington, USA
| | - Hermann Badolo
- Centre Muraz, Institut National de Santé Publique (INSP), Bobo-Dioulasso, Burkina Faso
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
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Procureur F, Estifanos AS, Keraga DW, Kiflie Alemayehu AK, Hailemariam NW, Schellenberg J, Magge H, Hill Z. "Quality teaches you how to use water. It doesn't provide a water pump": a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program. BMC Health Serv Res 2023; 23:381. [PMID: 37076845 PMCID: PMC10116784 DOI: 10.1186/s12913-023-09341-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/25/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives' varied impacts. METHODS To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. RESULTS The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. CONCLUSIONS The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.
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Affiliation(s)
- F Procureur
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK
| | - A S Estifanos
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - D W Keraga
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | - J Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - H Magge
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
- Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis Street, Boston, MA, 02115, USA
| | - Z Hill
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK.
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Tegenaw GS, Amenu D, Ketema G, Verbeke F, Cornelis J, Jansen B. Evaluating a clinical decision support point of care instrument in low resource setting. BMC Med Inform Decis Mak 2023; 23:51. [PMID: 36998074 PMCID: PMC10064719 DOI: 10.1186/s12911-023-02144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/15/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Clinical pathways are one of the main tools to manage the health care's quality and concerned with the standardization of care processes. They have been used to help frontline healthcare workers by presenting summarized evidence and generating clinical workflows involving a series of tasks performed by various people within and between work environments to deliver care. Integrating clinical pathways into Clinical Decision Support Systems (CDSSs) is a common practice today. However, in a low-resource setting (LRS), this kind of decision support systems is often not readily accessible or even not available. To fill this gap, we developed a computer aided CDSS that swiftly identifies which cases require a referral and which ones may be managed locally. The computer aided CDSS is designed primarily for use in primary care settings for maternal and childcare services, namely for pregnant patients, antenatal and postnatal care. The purpose of this paper is to assess the user acceptance of the computer aided CDSS at the point of care in LRSs. METHODS For evaluation, we used a total of 22 parameters structured in to six major categories, namely "ease of use, system quality, information quality, decision changes, process changes, and user acceptance." Based on these parameters, the caregivers from Jimma Health Center's Maternal and Child Health Service Unit evaluated the acceptability of a computer aided CDSS. The respondents were asked to express their level of agreement using 22 parameters in a think-aloud approach. The evaluation was conducted in the caregiver's spare-time after the clinical decision. It was based on eighteen cases over the course of two days. The respondents were then asked to score their level of agreement with some statements on a five-point scale: strongly disagree, disagree, neutral, agree, and strongly agree. RESULTS The CDSS received a favorable agreement score in all six categories by obtaining primarily strongly agree and agree responses. In contrast, a follow-up interview revealed a variety of reasons for disagreement based on the neutral, disagree, and strongly disagree responses. CONCLUSIONS Though the study had a positive outcome, it was limited to the Jimma Health Center Maternal and Childcare Unit, and hence a wider scale evaluation and longitudinal measurements, including computer aided CDSS usage frequency, speed of operation and impact on intervention time are needed.
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Affiliation(s)
- Geletaw Sahle Tegenaw
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), Pleinlaan 2, 1050, Brussels, Belgium.
- Faculty of Computing, JiT, Jimma University, Jimma, Ethiopia.
| | - Demisew Amenu
- Department of Obstetrics and Gynecology, College of Health Science, Jimma University, Jimma, Ethiopia
| | - Girum Ketema
- Faculty of Computing, JiT, Jimma University, Jimma, Ethiopia
| | - Frank Verbeke
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), Pleinlaan 2, 1050, Brussels, Belgium
| | - Jan Cornelis
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), Pleinlaan 2, 1050, Brussels, Belgium
| | - Bart Jansen
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), Pleinlaan 2, 1050, Brussels, Belgium
- Imec, Kapeldreef 75, 3001, Leuven, Belgium
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Dantas Gurgel G, Kristensen SR, da Silva EN, Gomes LB, Barreto JOM, Kovacs RJ, Sampaio J, Bezerra AFB, de Brito E Silva KS, Shimizu HE, de Sousa ANA, Fardousi N, Borghi J, Powell-Jackson T. Pay-for-performance for primary health care in Brazil: A comparison with England's Quality Outcomes Framework and lessons for the future. Health Policy 2023; 128:62-68. [PMID: 36481068 DOI: 10.1016/j.healthpol.2022.11.004] [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: 09/22/2021] [Revised: 10/13/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
Pay-for-performance (P4P) has been widely applied in OECD countries to improve the quality of both primary and secondary care, and is increasingly being implemented in low- and middle-income countries. In 2011, Brazil introduced one of the largest P4P schemes in the world, the National Programme for Improving Primary Care Access and Quality (PMAQ). We critically assess the design of PMAQ, drawing on a comparison with England's quality and outcome framework which, like PMAQ, was implemented at scale relatively rapidly within a nationalised health system. A key feature of PMAQ was that payment was based on the performance of primary care teams but rewards were given to municipalities, who had autonomy in how the funds could be used. This meant the incentives felt by family health teams were contingent on municipality decisions on whether to pass the funds on as bonuses and the basis upon which they allocated the funds between and within teams. Compared with England's P4P scheme, performance measurement under PMAQ focused more on structural rather than process quality of care, relied on many more indicators, and was less regular. While PMAQ represented an important new funding stream for primary health care, our review suggests that theoretical incentives generated were unclear and could have been better structured to direct health providers towards improvements in quality of care.
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Affiliation(s)
| | - Søren Rud Kristensen
- Institute of Global Health Innovation, Imperial College London, London, UK; Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark.
| | | | | | | | - Roxanne J Kovacs
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraiba, João Pessoa, Brazil.
| | | | | | - Helena Eri Shimizu
- Department of Collective Health, University of Brasilia, Brasilia, Brazil.
| | | | - Nasser Fardousi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
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Abraham JM, Melendez-Torres GJ. A realist review of interventions targeting maternal health in low- and middle-income countries. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231205687. [PMID: 37899651 PMCID: PMC10617292 DOI: 10.1177/17455057231205687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 09/04/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023]
Abstract
Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.
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Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence. BMC Pregnancy Childbirth 2022; 22:977. [PMID: 36577961 PMCID: PMC9795647 DOI: 10.1186/s12884-022-05331-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services. METHODS We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output). RESULTS Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services. CONCLUSION Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.
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Khatri RB, Assefa Y, Durham J. Assessment of health system readiness for routine maternal and newborn health services in Nepal: Analysis of a nationally representative health facility survey, 2015. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001298. [PMID: 36962692 PMCID: PMC10022376 DOI: 10.1371/journal.pgph.0001298] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/23/2022] [Indexed: 11/22/2022]
Abstract
Access to and utilisation of routine maternal and newborn health (MNH) services, such as antenatal care (ANC), and perinatal services, has increased over the last two decades in Nepal. The availability, delivery, and utilisation of quality health services during routine MNH visits can significantly impact the survival of mothers and newborns. Capacity of health facility is critical for the delivery of quality health services. However, little is known about health system readiness (structural quality) of health facilities for routine MNH services and associated determinants in Nepal. Data were derived from the Nepal Health Facility Survey (NHFS) 2015. Total of 901 health facilities were assessed for structural quality of ANC services, and 454 health facilities were assessed for perinatal services. Adapting the World Health Organization's Service Availability and Readiness Assessment manual, we estimated structural quality scores of health facilities for MNH services based on the availability and readiness of related subdomain-specific items. Several health facility-level characteristics were considered as independent variables. Logistic regression analyses were conducted, and the odds ratio (OR) was reported with 95% confidence intervals (CIs). The significance level was set at p-value of <0.05. The mean score of the structural quality of health facilities for ANC, and perinatal services was 0.62, and 0.67, respectively. The average score for the availability of staff (e.g., training) and guidelines-related items in health facilities was the lowest (0.37) compared to other four subdomains. The odds of optimal structural quality of health facilities for ANC services were higher in private health facilities (adjusted odds ratio (aOR) = 2.65, 95% CI: 1.48, 4.74), and health facilities supervised by higher authority (aOR = 1.96; CI: 1.22, 3.13) while peripheral health facilities had lower odds (aOR = 0.13; CI: 0.09, 0.18) compared to their reference groups. Private facilities were more likely (aOR = 1.69; CI:1.25, 3.40) to have optimal structural quality for perinatal services. Health facilities of Karnali (aOR = 0.29; CI: 0.09, 0.99) and peripheral areas had less likelihood (aOR = 0.16; CI: 0.10, 0.27) to have optimal structural quality for perinatal services. Provincial and local governments should focus on improving the health system readiness in peripheral and public facilities to deliver quality MNH services. Provision of trained staff and guidelines, and supply of laboratory equipment in health facilities could potentially equip facilities for optimal quality health services delivery. In addition, supervision of health staff and facilities and onsite coaching at peripheral areas from higher-level authorities could improve the health management functions and technical capacity for delivering quality MNH services. Local governments can prioritise inputs, including providing a trained workforce, supplying equipment for laboratory services, and essential medicine to improve the quality of MNH services in their catchment.
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Affiliation(s)
- Resham B. Khatri
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Health Social Science and Development Research Institute, Kathmandu, Nepal
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jo Durham
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
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Haemmerli M, Asante A, Susilo D, Satrya A, Fattah RA, Cheng Q, Kosen S, Novitasari D, Puteri GC, Adawiyah E, Hayen A, Gilson L, Mills A, Tangcharoensathien V, Jan S, Thabrany H, Wiseman V. Using measures of quality of care to assess equity in health care funding for primary care: analysis of Indonesian household data. BMC Health Serv Res 2022; 22:1349. [PMID: 36376946 PMCID: PMC9664775 DOI: 10.1186/s12913-022-08739-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. METHODS We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. RESULTS Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less 'pro-poor' while private clinics became more 'pro-rich' after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). CONCLUSIONS Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals' pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.
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Affiliation(s)
- Manon Haemmerli
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| | - Augustine Asante
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Dwidjo Susilo
- Faculty of Public Health, University of Indonesia, Jakarta, Indonesia
| | - Aryana Satrya
- Department of Management, Faculty of Economics, University of Indonesia, Depok, Indonesia
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
| | - Rifqi Abdul Fattah
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
| | - Qinglu Cheng
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Danty Novitasari
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
| | - Gemala Chairunnisa Puteri
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
- Centre for Health Economics and Policy Studies, University of Indonesia, Jakarta, Indonesia
| | - Eviati Adawiyah
- Faculty of Public Health, University of Indonesia, Jakarta, Indonesia
| | - Andrew Hayen
- School of Public Health, University of Technology Sydney, Sydney, Australia
| | - Lucy Gilson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Health Policy and Systems Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Anne Mills
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Kirby Institute, University of New South Wales, Sydney, Australia
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Chege T, Wafula F, Tama E, Khayoni I, Ogira D, Gitau N, Goodman C. How much does effective health facility inspection cost? An analysis of the economic costs of Kenya’s Joint Health Inspection innovations. BMC Health Serv Res 2022; 22:1351. [PMID: 36376860 PMCID: PMC9664811 DOI: 10.1186/s12913-022-08727-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background In most low- and middle-income countries, health facility regulation is fragmented, ineffective and under-resourced. The Kenyan Government piloted an innovative regulatory regime involving Joint Health Inspections (JHI) which synthesized requirements across multiple regulatory agencies; increased inspection frequency; digitized inspection tools; and introduced public display of regulatory results. The pilot significantly improved regulatory compliance. We calculated the costs of the development and implementation of the JHI pilot and modelled the costs of national scale-up in Kenya. Methods We calculated the economic costs of three phases: JHI checklist development, start-up activities, and first year of implementation, from the providers’ perspective in three pilot counties. Data collection involved extraction from expenditure records and key informant interviews. The annualized costs of JHI were calculated by adding annualized development and start-up costs to annual implementation costs. National level scale-up costs were also modelled and compared to those of current standard inspections. Results The total economic cost of the JHI pilot was USD 1,125,600 (2017 USD), with the development phase accounting for 19%, start-up 43% and the first year of implementation 38%. The annualized economic cost was USD 519,287, equivalent to USD 206 per health facility visit and USD 311 per inspection completed. Scale up to the national level, while replacing international advisors with local staff, was estimated to cost approximately USD 4,823,728, equivalent to USD 103 per health facility visit and USD 155 per inspection completed. This compares to an estimated USD 86,997 per year (USD 113 per inspection completed) spent on a limited number of inspections prior to JHI. Conclusion Information on costs is essential to consider affordability and value for money of regulatory interventions. This is the first study we are aware of costing health facility inspections in sub-Saharan Africa. It has informed debates on appropriate inspection design and potential efficiency gains. It will also serve as an important benchmark for future studies, and a key input into cost-effectiveness analyses. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08727-3.
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Abstract
IMPORTANCE In India, the district serves as the primary policy unit for implementing and allocating resources for various programs aimed at improving key developmental and health indicators. Recent evidence highlights that high-quality care for mothers and newborns is critical to reduce preventable mortality. However, the geographic variation in maternal and newborn health service quality has never been investigated. OBJECTIVE To examine the variation between smaller areas within districts in the quality of maternal and newborn care in India. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study assessed data from women aged 15 to 49 years on the most recent birth (singleton or multiples) in the 5 years that preceded the fifth National Family Health Survey (June 17, 2019, to April 30, 2021). EXPOSURES Maternal and newborn care in 36 states and union territories (UTs), 707 districts, and 28 113 clusters (small areas) in India. MAIN OUTCOMES AND MEASURES The composite quality score of maternal and newborn care was defined as the proportion of components of care received of the total 11 essential components of antenatal and postnatal care. Four-level logistic and linear regression was used for analyses of individual components of care and composite score, respectively. Precision-weighted prevalence of each component of care and mean composite score across districts as well as their between-small area SD were calculated. RESULTS The final analytic sample for the composite score was composed of 123 257 births nested in 28 113 small areas, 707 districts, and 36 states/UTs. For the composite score, 58.3% of the total geographic variance was attributable to small areas, 29.3% to states and UTs, and 12.4% to districts. Of 11 individual components of care, the small areas accounted for the largest proportion of geographic variation for 6 individual components of care (ranging from 42.3% for blood pressure taken to 73.0% for tetanus injection), and the state/UT was the largest contributor for 4 components of care (ranging from 41.7% for being weighed to 52.3% for ultrasound test taken). District-level composite score and prevalence of individual care components and their variation across small areas within the districts showed a consistently strong negative correlation (Spearman rank correlation ρ = -0.981 to -0.886). Low-quality scores and large between-small area disparities were not necessarily concentrated in aspirational districts (mean district composite score [SD within districts], 92.7% [2.1%] among aspirational districts and 93.7% [1.8%] among nonaspirational districts). CONCLUSIONS AND RELEVANCE The findings of this cross-sectional study suggest that the policy around maternal and child health care needs to be designed more precisely to consider district mean and between-small area heterogeneity in India. This study may have implications for other low- and middle-income countries seeking to improve maternal and newborn outcomes, particularly for large countries with geographic heterogeneity.
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Affiliation(s)
- Hwa-Young Lee
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Institute of Convergence Science, Convergence Science Academy, Yonsei University, Seoul, South Korea
| | - Md Juel Rana
- Korea University Research and Business Foundation, Seoul, South Korea
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
| | - S. V. Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Brima N, Morhason-Bello IO, Charles V, Davies J, Leather AJ. Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions. BMJ Open 2022; 12:e062616. [PMID: 36220318 PMCID: PMC9557325 DOI: 10.1136/bmjopen-2022-062616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to evaluate the impact of the intervention and implementation learning. DESIGN We conducted a systematic literature review and narrative synthesis. SETTING Literature on hospital-based quality improvement studies in sub-Saharan Africa reviewed until 31 December 2021. PARTICIPANTS MEDLINE, EMBASE, Global Health, CINAHL, Web of Science databases and grey literature were searched. INTERVENTION We extracted data on intervention characteristics and how the intervention was delivered and evaluated. PRIMARY AND SECONDARY OUTCOME MEASURES Importantly, we assessed whether clinical, process and implementation outcomes were collected and separately categorised the outcomes under the Institute of Medicine quality domains. Risk of bias was not assessed. RESULTS Of 1573 articles identified, 49 were included from 17/48 sub-Saharan African countries, 16 of which were low-income or lower middle-income countries. Almost two-thirds of the studies took place in East Africa (31/49, 63.2%). The most common intervention focus was reduction of surgical site infection (12/49, 24.5%) and use of a surgical safety checklist (14/49, 28.6%). Use of implementation and quality improvement science methods were rare. Over half the studies measured clinical outcomes (29/49, 59.2%), with the most commonly reported ones being perioperative mortality (13/29, 44.8%) and surgical site infection rate (14/29, 48.3%). Process and implementation outcomes were reported in over two thirds of the studies (34/49, 69.4% and 35, 71.4%, respectively). The most studied quality domain was safety (44/49, 89.8%), with efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) the least studied domains. CONCLUSIONS There are few hospital-based studies that focus on improving the quality of surgical and anaesthesia care in sub-Saharan Africa. Use of implementation and quality improvement methodologies remain low, and some quality domains are neglected. PROSPERO REGISTRATION NUMBER CRD42019125570.
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Affiliation(s)
- Nataliya Brima
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Imran O Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine/University College Hospital, University of Ibadan, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | | | - Justine Davies
- University of Birmingham Institute of Applied Health Research, Birmingham, UK
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Kim MK, Kim SA, Oh J, Kim CE, Arsenault C. Measuring effective coverage of maternal and child health services in Cambodia: a retrospective analysis of Demographic and Health Surveys from 2005 to 2014. BMJ Open 2022; 12:e062028. [PMID: 36691182 PMCID: PMC9454061 DOI: 10.1136/bmjopen-2022-062028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/09/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To investigate effective, quality-adjusted, coverage and inequality of maternal and child health (MCH) services to assess progress in improving quality of care in Cambodia. DESIGN A retrospective secondary analysis using the three most recent (2005, 2010 and 2014) Demographic and Health Surveys. SETTING Cambodia. PARTICIPANTS 53 155 women aged 15-49 years old and 23 242 children under 5 years old across the three surveys. OUTCOME MEASURES We estimated crude coverage, effective coverage and inequality in effective coverage for five MCH services over time: antenatal care (ANC), facility delivery and sick childcare for diarrhoea, pneumonia and fever. Quality was defined by the proportion of care seekers who received a set of interventions during healthcare visits. Effective coverage was estimated by combining crude coverage and quality. We used equiplots and risk ratios, to assess patterns in inequality in MCH effective coverage across wealth quintile, urban-rural and women's education levels and over time. RESULTS In 2014, crude and effective coverage was 80.1% and 56.4%, respectively, for maternal health services (ANC and facility delivery) and 59.1% and 26.9%, respectively, for sick childcare (diarrhoea, pneumonia and fever). Between 2005 and 2014, effective coverage improved for all services, but improvements were larger for maternal healthcare than for sick child care. In 2014, poorer children were more likely to receive oral rehydration solution for diarrhoea than children from richer households. Meanwhile, women from urban areas were more likely to receive a postnatal check before getting discharged. CONCLUSIONS Effective coverage has generally improved in Cambodia but efforts remain to improve quality for all MCH services. Our results point to substantial gaps in curative sick child care, a large share of which is provided by unregulated private providers in Cambodia. Policymakers should focus on improving effective coverage, and not only crude coverage, to achieve the health-related Sustainable Development Goals by 2030.
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Affiliation(s)
- Min Kyung Kim
- Department of Korea, Korea Foundation for International Healthcare, Seoul, Republic of Korea
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Soon Ae Kim
- Department of Korea, Korea Foundation for International Healthcare, Seoul, Republic of Korea
| | - Juhwan Oh
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chae Eun Kim
- Department of Korea, Korea Foundation for International Healthcare, Seoul, Republic of Korea
| | - Catherine Arsenault
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Quality of emergency obstetric and newborn care services in Wolaita Zone, Southern Ethiopia. BMC Pregnancy Childbirth 2022; 22:686. [PMID: 36068531 PMCID: PMC9446841 DOI: 10.1186/s12884-022-05019-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: 11/16/2021] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Background Globally, nearly 295,000 women die every year during and following pregnancy and childbirth. Emergency obstetric and newborn care (EmONC) can avert 75% of maternal mortality if all mothers get quality healthcare. Improving maternal health needs identification and addressing of barriers that limit access to quality maternal health services. Hence, this study aimed to assess the quality of EmONC service and its predictors in Wolaita Zone, southern Ethiopia. Methodology A facility-based cross-sectional study was conducted in 14 health facilities. A facility audit was conducted on 14 health facilities, and 423 women were randomly selected to participate in observation of care and exit interview. The Open Data Kit (ODK) platform and Stata version 17 were used for data entry and analysis, respectively. Frequencies and summary statistics were used to describe the study population. Simple and multiple linear regressions were done to identify candidate and predictor variables of service quality. Coefficients with 95% confidence intervals were used to declare the significance and strength of association. Input, process, and output quality indices were created by calculating the means of standard items available or actions performed by each category and were used to describe the quality of EmONC. Result The mean input, process, and output EmONC services qualities were 74.2, 69.4, and 79.6%, respectively. Of the study participants, 59.2% received below 75% of the standard clinical actions (observed quality) of EmONC services. Women’s educational status (B = 5.35, 95% C.I: 0.56, 10.14), and (B = 8.38, 95% C.I: 2.92, 13.85), age (B = 3.86, 95% C.I: 0.39, 7.33), duration of stay at the facility (B = 3.58, 95% C.I: 2.66, 4.9), number of patients in the delivery room (B = − 4.14, 95% C.I: − 6.14, − 2.13), and care provider’s experience (B = 1.26, 95% C.I: 0.83, 1.69) were independent predictors of observed service quality. Conclusion The EmONC services quality was suboptimal in Wolaita Zone. Every three-in-five women received less than three-fourths of the standard clinical actions. The health system, care providers, and other stakeholders should emphasize improving the quality of care by availing medical infrastructure, adhering to standard procedures, enhancing human resources for health, and providing standard care regardless of women’s characteristics.
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Tama E, Khayoni I, Goodman C, Ogira D, Chege T, Gitau N, Wafula F. What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya's Health Facility Inspection Reforms. Int J Health Policy Manag 2022; 11:1852-1862. [PMID: 34634878 PMCID: PMC9808232 DOI: 10.34172/ijhpm.2021.90] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/19/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Health facility regulation in low- and middle-income countries (LMICs) is generally weak, with potentially serious consequences for safety and quality. Innovative regulatory reforms were piloted in three Kenyan counties including: a Joint Health Inspection Checklist (JHIC) synthesizing requirements across multiple regulatory agencies; increased inspection frequency; allocating facilities to compliance categories which determined warnings, sanctions and/or time to re-inspection; and public display of regulatory results. The reforms substantially increased inspection scores compared with control facilities. We developed lessons for future regulatory policy from this pilot by identifying key factors that facilitated or hindered its implementation. METHODS We conducted a qualitative study to understand views and experiences of actors involved in the one-year pilot. We interviewed 77 purposively selected staff from the national, county and facility levels. Data were analyzed using the framework approach, identifying facilitating/hindering factors at the facility, inspection system, and health system levels. RESULTS The joint health inspections (JHIs) were generally viewed as fair, objective and transparent, which enhanced their perceived legitimacy. Interactions with inspectors were described as friendly and supportive, in contrast to the punitive culture of previous inspections when bribery had been common. Inspector training and use of an electronic checklist were strongly praised. However, practical challenges with transport, route planning and budgets highlighted the critical nature of strong logistical management. The effectiveness of inspection in improving compliance was hampered by limitations in related systems, particularly facility licensing, enforcement of closures and, in the public sector, control of funds. However, an inclusive reform development process had led to high buy-in across regulatory agencies which was key to the system's success. CONCLUSION Effective facility inspection involves more than "hardware" such as checklists, protocols and training. Cultural, relational and institutional "software" are also crucial for legitimacy, feasibility of implementation and enforceability, and should be carefully integrated into regulatory reforms.
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Affiliation(s)
- Eric Tama
- Institute of Healthcare Management, Strathmore University Business School, Strathmore University, Nairobi, Kenya
| | - Irene Khayoni
- Institute of Healthcare Management, Strathmore University Business School, Strathmore University, Nairobi, Kenya
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - Dosila Ogira
- Institute of Healthcare Management, Strathmore University Business School, Strathmore University, Nairobi, Kenya
| | - Timothy Chege
- Institute of Healthcare Management, Strathmore University Business School, Strathmore University, Nairobi, Kenya
| | | | - Francis Wafula
- Institute of Healthcare Management, Strathmore University Business School, Strathmore University, Nairobi, Kenya
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Clarke-Deelder E, Afriyie DO, Nseluke M, Masiye F, Fink G. Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia. BMC Public Health 2022; 22:1205. [PMID: 35710372 PMCID: PMC9202228 DOI: 10.1186/s12889-022-13549-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/24/2022] [Indexed: 11/15/2022] Open
Abstract
Background In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce. Methods We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals. Results A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies. Conclusions The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13549-3.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Doris Osei Afriyie
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Mweene Nseluke
- Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka, Zambia
| | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Günther Fink
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Madeiro A, Rufino AC, Nunes MDDS, Martins VMML, Barbosa CM, Sousa AMCD, Acaqui RF. Analysis of the structural adequacy of maternity hospitals in Piauí, Brazil, 2018-2019. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2022. [DOI: 10.1590/1806-9304202200020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract Objectives: to evaluate the structure and adequacy of maternal healthcare facilities in Piauí. Methods: cross-sectional study in 26 hospitals with more than 200 births/year between 2018-2019. The structure was assessed by direct observation and interview with manager, in four domains: physical aspects, human resources, equipment, and drugs. Fisher’s chi-square/exact tests were used to assess differences in adequacy of structure. Results: only 46.2% of the maternal healthcare facilities had pre-delivery, parturition and immediate post-partum room. Pediatricians (73.1%) and anesthesiologists (61.5%) were the least present professionals on-duty regime. Regarding drugs, magnesium sulfate and oxytocin were observed in 76.9% of hospitals. Overall adequacy was 23.1%, being higher in maternal healthcare facilities in the capital (p=0.034) and in private ones (p=0.031). Conclusions: Data show inequalities in the structure of maternity hospitals of the state. The absence of health professionals, essential drugs, and appropriate physical structure can expose women and newborns to unnecessary and avoidable risks.
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Kuguyo O, Chirenda J, Chikwasha V, Mukona DM, Mageza A, Gwanzura L, Matimba A. Needs assessment of diabetic foot services in Zimbabwe. Diabetes Res Clin Pract 2022; 188:109925. [PMID: 35577036 DOI: 10.1016/j.diabres.2022.109925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Due to the increasing incidence of diabetes in Zimbabwe, complications such as diabetic foot (DF) are anticipated. Establishing local gaps and needs in DF healthcare is paramount for tailoring management strategies. AIMS To determine the status of DF services in the healthcare system and explore awareness of DF management and practices among registered general nurses (RGNs) in Zimbabwe. METHODS A mixed-methods approach was applied. Thirty-one RGNs from 16 public health facilities in Harare, Zimbabwe attending a DF workshop were administered with a cross-sectional survey instrument and a semi-structured questionnaire. Data collected included presence/absence of DF services and podiatrists in healthcare facilities, healthcare system approaches in DF care and availability of DF training/education programs for RGNs. Analysis was performed using Stata and Nvivo software. RESULTS No respondents reported availability of podiatrists. Only 1 (3%) of RGNs reported DF screening in primary care. Sixty percent (18) did not know or had never screened for DF. The RGNs reported inadequate DF educational programs/modules in primary care settings. CONCLUSION This data highlights a need to improve DF education for RGNs at the frontline of managing PLWD. Understanding the needs for DF services may guide interventions to improve education and awareness programs that are appropriately tailored to local constraints in the health system. The non-communicable diseases director is encouraged to develop DF educational programmes for frontline health care workers.
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Affiliation(s)
- Oppah Kuguyo
- University of Zimbabwe, Faculty of Medicine and Health Sciences, P.O. Box A178, Avondvale, Harare, Zimbabwe.
| | - Joconiah Chirenda
- University of Zimbabwe, Faculty of Medicine and Health Sciences, P.O. Box A178, Avondvale, Harare, Zimbabwe.
| | - Vasco Chikwasha
- University of Zimbabwe, Faculty of Medicine and Health Sciences, P.O. Box A178, Avondvale, Harare, Zimbabwe.
| | - Doreen Macherera Mukona
- University of Zimbabwe, Faculty of Medicine and Health Sciences, P.O. Box A178, Avondvale, Harare, Zimbabwe; Parirenyatwa Group of Hospitals, Department of Surgery, Parirenyatwa Complex, Mazowe Street, Harare, Zimbabwe.
| | - Akimu Mageza
- Parirenyatwa Group of Hospitals, Department of Surgery, Parirenyatwa Complex, Mazowe Street, Harare, Zimbabwe.
| | - Lovemore Gwanzura
- University of Zimbabwe, Faculty of Medicine and Health Sciences, P.O. Box A178, Avondvale, Harare, Zimbabwe.
| | - Alice Matimba
- University of Zimbabwe, Faculty of Medicine and Health Sciences, P.O. Box A178, Avondvale, Harare, Zimbabwe.
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Kagawa MN, Kiguli S, Steinberg H, Jama MP. Perceptions of Lecturers, Administrators, and Students About the Workplace as Learning Environment for Undergraduate Medical Students at a National Referral and Teaching Hospital in Uganda. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2022; 13:555-566. [PMID: 35651478 PMCID: PMC9150918 DOI: 10.2147/amep.s357003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The workplace is an important element of the learning ecosystem for medical students during their competence development. It offers engagement opportunities that enable students to participate in clinical activities as part of learning in their preparation for future clinical practice. The purpose of this study was to explore the perceptions and experiences of lecturers, administrators, and students of Makerere University College of Health Sciences about the workplace, at Mulago National Referral and Teaching Hospital, as a learning environment for the undergraduate medical students with the ultimate aim of identifying opportunities and challenges to learner competence development in the learning environment for purposes of improvement. METHODS The study design was cross-sectional descriptive with a qualitative approach using key informant interviews for the lecturers and administrators and focus group discussions for the students. The framework method was used to perform thematic data analysis. RESULTS The workplace was perceived to be well endowed with adequate patient numbers, a suitable case mix and unrestricted access to patients which enhanced competence development. The challenges reported included inadequate resources, such as infrastructure, equipment and supplies and overcrowding, which compromised competence development. The resource challenge appeared insurmountable in the context of two autonomous institutions with divergent planning priorities in terms of teaching, research, and patient care. CONCLUSION There were mixed perceptions about the learning environment at the hospital with both enabling and challenging factors on the backdrop of two autonomous institutions with divergent planning priorities in terms of teaching, research, and patient care. In order to improve the workplace as a learning environment, it is imperative that the two institutions find common ground in terms of clinical care, students' teaching and provision of supplies that are essential not only for patient care but competence development of the learners who are the clinicians of tomorrow.
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Affiliation(s)
- Mike Nantamu Kagawa
- Department of Obstetrics & Gynaecology, Makerere University, Kampala, Uganda
| | - Sarah Kiguli
- Department of Paediatrics & Child health, Makerere University, Kampala, Uganda
| | - Hannes Steinberg
- Department of Family Medicine, University of the Free State, Bloemfontein, Republic of South Africa
| | - Mpho Priscilla Jama
- Division Student Learning and Development, Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, Republic of South Africa
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Brenner S, Madhavan S, Nseya CK, Sese C, Fink G, Shapira G. Competent and deficient provision of childbirth services: a descriptive observational study assessing the quality of intrapartum care in two provinces of the Democratic Republic of the Congo. BMC Health Serv Res 2022; 22:551. [PMID: 35468822 PMCID: PMC9040341 DOI: 10.1186/s12913-022-07737-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/25/2022] [Indexed: 11/28/2022] Open
Abstract
Background A majority of women in the Democratic Republic of the Congo (DRC) give birth in a health facility, but maternal and newborn mortality remains high. In rural areas, the quality of facility-based delivery care is often low. This study examines clinical quality of intrapartum care in two provinces of the DRC. Methods We observed process and input elements of delivery care provision at 29 facilities in Kwilu and Kwango provinces. Distinguishing non-performance attributable to provider behavior vs. input constraints, we compared both providers’ adherence to clinical standards (“competent care”) and non-adherence to processes for which required inputs were available (“deficient care”). Results Observing a total of 69 deliveries, care was most competent for partograph use (75% cases) and hemorrhage prevention (73%), but least for postpartum monitoring (4%). Competent care was significantly associated with higher case volumes (p = ·03), skilled birth attendance (p = ·05), and nulliparous women (p = ·02). Care was most deficient for infection prevention (62%) and timely care (49%) and associated with cases observed at hospitals and lower delivery volume. Conclusions Low quality was commonly not a result of missing equipment or supplies but related to providers’ non-adherence to standard protocols. Low case volumes and the absence of skilled attendants seemed to be main factors for sub-standard quality care. Birth assistance during labor stage 2 was the only intrapartum stage heavily affected by the unavailability of essential equipment. Future interventions should strengthen links between birth attendants’ practice to clinical protocols.
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Affiliation(s)
- Stephan Brenner
- Heidelberg Institute of Global Health, University Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
| | - Supriya Madhavan
- Global Financing Facility and The World Bank, Washington, DC, USA
| | - Céline Kanionga Nseya
- Institut Supérieur des Techniques Médicales, Kinshasa, Democratic Republic of the Congo.,Bureau Appui Technique, Division Provinciale de la Santé, Kinshasa, Democratic Republic of the Congo
| | - Claude Sese
- Programme de Développement du Système de Santé (PDSS), Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Gil Shapira
- Development Research Group (DECRG), The World Bank, Washington, DC, USA
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Dubas-Jakóbczyk K, Kozieł A. European Union Structural Funds as the Source of Financing Health Care Infrastructure Investments in Poland—A Longitudinal Analysis. Front Public Health 2022; 10:873433. [PMID: 35400058 PMCID: PMC8989962 DOI: 10.3389/fpubh.2022.873433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
European Union (EU) structural funds aim at reducing economic and social disparities between the member states regions. The objectives of the study were to (1) provide a summary overview of all health related projects co-financed by EU structural funds in Poland between 2004 and 2020, (2) define the share of projects/funds devoted to infrastructure investments, and (3) assess the total value of EU structural funds' contribution to health care infrastructure investments in comparison to the national public budgets. Data on projects co-financed by EU structural funds covered all projects realized under three financial perspectives: 2004–2006; 2007–2013; 2014–2020. The extraction of “health-related” projects was done according to both the type priority under which the project was realized as well as the type of beneficiary. Results showed that between 2004 and 2020, 14,179 health related projects were implemented, with a total value of 33.2 billion PLN, including EU contribution of 22.8 billion PLN (68.7%). Although projects focused on education and public health prevailed in terms of their total number, infrastructural projects consumed the vast majority of funds. Within the analyzed period, a total of 6,689 health infrastructure projects were implemented with a total value of 29.5 billion PLN, including 19.7 billion PLN of EU contributions. The results confirm that the EU structural funds constituted an important source of infrastructural investments in the Polish health system and majority of them were consumed by investments in public hospitals.
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Affiliation(s)
- Katarzyna Dubas-Jakóbczyk
- Health Economics and Social Security Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
- *Correspondence: Katarzyna Dubas-Jakóbczyk ; orcid.org/0000-0002-6368-2868
| | - Anna Kozieł
- Health, Nutrition and Population, World Bank, The World Bank Office in Poland, Warsaw, Poland
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Lofgren KT, Bobanski L, Tuller DE, Singh VP, Marx Delaney M, Jurczak A, Ragavan M, Kalita T, Karlage A, Resch SC, Semrau KEA. Estimating maternity ward birth attendant time use in India: a microcosting study. BMJ Open 2022; 12:e054164. [PMID: 35131826 PMCID: PMC8823136 DOI: 10.1136/bmjopen-2021-054164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/11/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Despite global concern over the quality of maternal care, little is known about the time requirements to complete the essential birth practices. Using three microcosting data collection methods within the BetterBirth trial, we aimed to assess time use and the specific time requirements to incorporate the WHO Safe Childbirth Checklist into clinical practice. SETTING We collected detailed survey data on birth attendant time use within the BetterBirth trial in Uttar Pradesh, India. The BetterBirth trial tested whether the peer-coaching-based implementation of the WHO Checklist was effective in improving the quality of facility-based childbirth care. PARTICIPANTS We collected measurements of time to completion for 18 essential birth practices from July 2016 through October 2016 across 10 facilities in five districts (1559 total timed observations). An anonymous survey asked about the impact of the WHO Checklist on birth attendants at every intervention facility (15 facilities, 83 respondents) in the Lucknow hub. Additionally, data collectors visited facilities to conduct a census of patients and birth attendants across 20 facilities in seven districts between June 2016 and November 2016 (six hundred and ten 2-hour facility observations). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure of this study is the per cent of staff time required to complete the essential birth practices included in the WHO Checklist. RESULTS When birth attendants were timed, we found practices were completed rapidly (18 s to 2 min). As the patient load increased, time dedicated to clinical care increased but remained low relative to administrative and downtime. On average, WHO Checklist clinical care accounted for less than 7% of birth attendant time use per hour. CONCLUSIONS We did not find that a coaching-based implementation of the WHO Checklist was a burden on birth attendant's time use. However, questions remain regarding the performance quality of practices and how to accurately capture and interpret idle and break time. TRIAL REGISTRATION NUMBER NCT02148952.
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Affiliation(s)
- Katherine T Lofgren
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA
| | - Lauren Bobanski
- Ariadne Labs, Harvard T H Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Danielle E Tuller
- Ariadne Labs, Harvard T H Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vinay P Singh
- Population Services International, Lucknow, India
- Community Empowerment Lab, Lucknow, India
| | - Megan Marx Delaney
- Ariadne Labs, Harvard T H Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amanda Jurczak
- Ariadne Labs, Harvard T H Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Meera Ragavan
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Tapan Kalita
- Piramal Swasthya Management and Research Institute, Hyderabad, India
| | - Ami Karlage
- Ariadne Labs, Harvard T H Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephen Charles Resch
- Center for Health Decision Science, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Katherine E A Semrau
- Ariadne Labs, Harvard T H Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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35
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Dinsa GD, Dessie E, Hurlburt S, Gebreyohannes Y, Arsenault C, Yakob B, Girma T, Berman P, Kruk ME. Equitable Distribution of Poor Quality of Care? Equity in Quality of Reproductive Health Services in Ethiopia. Health Syst Reform 2022; 8:e2062808. [PMID: 36534168 DOI: 10.1080/23288604.2022.2062808] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The Ethiopian health system faces persistent inequities in health-care utilization and outcomes, despite continued efforts to expand health service coverage. There is little evidence in the literature describing the status of equity in the quality of healthcare. This paper aims to understand the disparities in quality of antenatal care (ANC) and family planning (FP) among the poor and non-poor communities. We used the 2016 Ethiopia Demographic and Health Survey (DHS) data to compute a Multidimensional Poverty Index (MPI), and the 2014 Service Provision Assessment (SPA) data to assess quality of ANC and FP services-defined as the level of adherence to World Health Organization (WHO) clinical and service guidelines. We merged the two datasets using geographical coordinates, and aggregated service users into facility catchment area clusters using a 2-km radius for urban and 10-km radius for rural facilities. We computed ANC and FP quality and MPI indices for each facility and assigned these to catchment areas. Using the international cutoff point for deprivation (MPI = 33.3%), we evaluated whether the quality of ANC and FP services varies by poor and non-poor catchment areas. We found that most of catchment areas (75.7%) were deprived. While the overall quality of ANC and FP services are low (33% and 34% respectively), we found little variation in the distribution of the quality of these services between poor and non-poor areas, urban and rural settings, or regionally. The short-term focus needs to be on improving the overall quality of services rather than on its distribution.
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Affiliation(s)
- Girmaye D Dinsa
- Department of Public Health and Health Policy, School of Population and Public Health University of British Columbia, Vancouver, BC Canada.,Department of Public Health and Health Policy, College of Health Sciences Haramaya University, Harar, Ethiopia.,Fenot Project, Department of Global Health and Population Harvard T. H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Ermias Dessie
- World Health Organization, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Sarah Hurlburt
- Fenot Project, Department of Global Health and Population Harvard T. H. Chan School of Public Health, Addis Ababa, Ethiopia
| | | | - Catherine Arsenault
- Fenot Project, Department of Global Health and Population, Harvard T. H. School of Public Health, Boston, MA, USA
| | - Bereket Yakob
- Fenot Project, Department of Global Health and Population Harvard T. H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Tsinuel Girma
- Fenot Project, Department of Global Health and Population Harvard T. H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Peter Berman
- Fenot Project, Department of Global Health and Population, Harvard T. H. School of Public Health, Boston, MA, USA
| | - Margaret E Kruk
- Fenot Project, Department of Global Health and Population, Harvard T. H. School of Public Health, Boston, MA, USA
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36
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Mallick LM, Amo-Adjei J. A Call to Action: Reinvigorating Interest and Investments in Health Infrastructure. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:711-715. [PMID: 34933968 PMCID: PMC8691883 DOI: 10.9745/ghsp-d-21-00674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/16/2021] [Indexed: 11/15/2022]
Abstract
Infrastructure investments can contribute substantially to alleviating burdens of morbidity and mortality while also providing a positive return on investment in the long term.
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Affiliation(s)
- Lindsay M Mallick
- Department of Family Science, Maternal and Child Health Program, School of Public Health, University of Maryland, College Park, MD, USA.
- Maryland Population Research Center, College Park, MD, USA
- Avenir Health, Glastonbury, CT, USA
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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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Pineda-Antunez C, Contreras-Loya D, Rodriguez-Atristain A, Opuni M, Bautista-Arredondo S. Characterizing health care provider knowledge: Evidence from HIV services in Kenya, Rwanda, South Africa, and Zambia. PLoS One 2021; 16:e0260571. [PMID: 34855816 PMCID: PMC8638969 DOI: 10.1371/journal.pone.0260571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 11/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Identifying approaches to improve levels of health care provider knowledge in resource-poor settings is critical. We assessed level of provider knowledge for HIV testing and counseling (HTC), prevention of mother-to-child transmission (PMTCT), and voluntary medical male circumcision (VMMC). We also explored the association between HTC, PMTCT, and VMMC provider knowledge and provider and facility characteristics. METHODS We used data collected in 2012 and 2013. Vignettes were administered to physicians, nurses, and counselors in facilities in Kenya (66), Rwanda (67), South Africa (57), and Zambia (58). The analytic sample consisted of providers of HTC (755), PMTCT (709), and VMMC (332). HTC, PMTCT, and VMMC provider knowledge scores were constructed using item response theory (IRT). We used GLM regressions to examine associations between provider knowledge and provider and facility characteristics focusing on average patient load, provider years in position, provider working in another facility, senior staff in facility, program age, proportion of intervention exclusive staff, person-days of training in facility, and management score. We estimated three models: Model 1 estimated standard errors without clustering, Model 2 estimated robust standard errors, and Model 3 estimated standard errors clustering by facility. RESULTS The mean knowledge score was 36 for all three interventions. In Model 1, we found that provider knowledge scores were higher among providers in facilities with senior staff and among providers in facilities with higher proportions of intervention exclusive staff. We also found negative relationships between the outcome and provider years in position, average program age, provider working in another facility, person-days of training, and management score. In Model 3, only the coefficients for provider years in position, average program age, and management score remained statistically significant at conventional levels. CONCLUSIONS HTC, PMTCT, and VMMC provider knowledge was low in Kenya, Rwanda, South Africa, and Zambia. Our study suggests that unobservable organizational factors may facilitate communication, learning, and knowledge. On the one hand, our study shows that the presence of senior staff and staff dedication may enable knowledge acquisition. On the other hand, our study provides a note of caution on the potential knowledge depreciation correlated with the time staff spend in a position and program age.
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Affiliation(s)
- Carlos Pineda-Antunez
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | - David Contreras-Loya
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Alejandra Rodriguez-Atristain
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | | | - Sergio Bautista-Arredondo
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
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Pattnaik A, Mohan D, Tsui A, Chipokosa S, Katengeza H, Ndawala J, Marx MA. The aggregate effect of implementation strength of family planning programs on modern contraceptive use at the health systems level in rural Malawi. PLoS One 2021; 16:e0232504. [PMID: 34780507 PMCID: PMC8592450 DOI: 10.1371/journal.pone.0232504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 10/29/2021] [Indexed: 11/20/2022] Open
Abstract
To explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility's catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve. We used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength. Metrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.
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Affiliation(s)
- Anooj Pattnaik
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Amy Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Hans Katengeza
- Reproductive Health Directorate, Ministry of Health, Lilongwe, Malawi
| | | | - Melissa A. Marx
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Haemmerli M, Powell-Jackson T, Goodman C, Thabrany H, Wiseman V. Poor quality for the poor? A study of inequalities in service readiness and provider knowledge in Indonesian primary health care facilities. Int J Equity Health 2021; 20:239. [PMID: 34736459 PMCID: PMC8567576 DOI: 10.1186/s12939-021-01577-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND For many low and middle-income countries poor quality health care is now responsible for a greater number of deaths than insufficient access to care. This has in turn raised concerns around the distribution of quality of care in LMICs: do the poor have access to lower quality health care compared to the rich? The aim of this study is to investigate the extent of inequalities in the availability of quality health services across the Indonesian health system with a particular focus on differences between care delivered in the public and private sectors. METHODS Using the Indonesian Family Life Survey (wave 5, 2015), 15,877 households in 312 communities were linked with a representative sample of both public and private health facilities available in the same communities. Quality of health facilities was assessed using both a facility service readiness score and a knowledge score constructed using clinical vignettes. Ordinary least squares regression models were used to investigate the determinants of quality in public and private health facilities. RESULTS In both sectors, inequalities in both quality scores existed between major islands. In public facilities, inequalities in readiness scores persisted between rural and urban areas, and to a lesser extent between rich and poor communities. CONCLUSION In order to reach the ambitious stated goal of reaching Universal Health Coverage in Indonesia, priority should be given to redressing current inequalities in the quality of care.
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Affiliation(s)
- Manon Haemmerli
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK.
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK
| | - Hasbullah Thabrany
- Centre for Health Economics and Policy Studies, University of Indonesia, Jakarta, Indonesia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK
- Kirby Institute, University of New South Wales, Sydney, Australia
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Giltenane M, Sheridan A, Kroll T, Frazer K. Identification of quality indicators of public health nursing practice: "modified Delphi" approach. Public Health Nurs 2021; 39:214-228. [PMID: 34697828 DOI: 10.1111/phn.13000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/10/2021] [Accepted: 10/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Identify process indicators to measure public health nursing practice during first postnatal visits in Ireland. DESIGN Using a RAND/UCLA appropriateness- "modified Delphi" method, a two-round rating and ranking process was completed in 2016. Fifty-nine statements were reviewed for consensus and priority ranking. SAMPLE The sample comprised a panel of 21 national and international experts. RESULTS Fifty-nine indicators were identified and subsequently reduced across two rounds of consensus testing. Fifty-six indicators achieved consensus and priority ranking identified 13 indicators to measure care for mothers and 15 indicators to measure care for newborns resulting in 28 process indicators to enable Public Health Nurses (PHNs) to measure care during the first postnatal visit. CONCLUSIONS Measurement of care using quality indicators plays an integral role in quality improvement. Developing quality indicators is important in improving care outcomes. This two round "modified Delphi" study combined with literature and previous qualitative findings identified process indicators to measure public health nursing practice at first postnatal visits and enables benchmarking. Developing quality indicators for public health nursing practice using a "modified Delphi" technique has enabled a platform to provide consensus amongst a panel of experts and identified key processes of care by PHNs and mothers.
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Affiliation(s)
- Martina Giltenane
- Lecturer in Nursing/Program Director Master in Health Sciences (Public Health Nursing), Room 410 School of Nursing and Midwifery, Aras Moyola, National University of Ireland, Galway, Ireland
| | - Ann Sheridan
- Lecturer and Researcher Mental Health, Subject Head-Mental Health Nursing, Chairperson Irish Institute of Mental Health Nursing, UCD School of Nursing, Midwifery & Health Systems, Room B310 UCD Health Sciences Centre, University College Dublin, Belfield, Dublin 4, Ireland
| | - Thilo Kroll
- Professor of Health Systems Management, Associate Dean for Research, Innovation and Impact, UCD School of Nursing, Midwifery and Health Systems, Fellow at the UCD Geary Institute for Public Policy, Room B225 UCD Health Sciences Centre, University College Dublin (UCD), Belfield, Dublin 4, Ireland
| | - Kate Frazer
- Director Graduate Research, Head of Subject: Public Health and Community Nursing, Fellow European Academy Nursing Science, Fellow UCD Geary Institute Public Policy, Room B224, UCD School of Nursing, Midwifery and Health Systems, UCD College of Health and Agricultural Sciences, Belfield, Dublin 4, Ireland
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Owolabi O, Riley T, Otupiri E, Polis CB, Larsen-Reindorf R. The infrastructural capacity of Ghanaian health facilities to provide safe abortion and post-abortion care: a cross-sectional study. BMC Health Serv Res 2021; 21:1104. [PMID: 34654428 PMCID: PMC8520210 DOI: 10.1186/s12913-021-07141-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/29/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ghana is one of few countries in sub-Saharan Africa with relatively liberal abortion laws, but little is known about the availability and quality of abortion services nationally. The aim of this study was to describe the availability and capacity of health facilities to deliver essential PAC and SAC services in Ghana. METHODS We utilized data from a nationally representative survey of Ghanaian health facilities capable of providing post-abortion care (PAC) and/or safe abortion care (SAC) (n = 539). We included 326 facilities that reported providing PAC (57%) or SAC (19%) in the preceding year. We utilized a signal functions approach to evaluate the infrastructural capacity of facilities to provide high quality basic and comprehensive care. We conducted descriptive analysis to estimate the proportion of primary and referral facilities with capacity to provide SAC and PAC and the proportion of SAC and PAC that took place in facilities with greater capacity, and fractional regression to explore factors associated with higher structural capacity for provision. RESULTS Less than 20% of PAC and/or SAC providing facilities met all signal function criteria for basic or comprehensive PAC or for comprehensive SAC. Higher PAC caseloads and staff trained in vacuum aspiration was associated with higher capacity to provide PAC in primary and referral facilities, and private/faith-based ownership and rural location was associated with higher capacity to provide PAC in referral facilities. Primary facilities with a rural location were associated with lower basic SAC capacity. DISCUSSION Overall very few public facilities have the infrastructural capacity to deliver all the signal functions for comprehensive abortion care in Ghana. There is potential to scale-up the delivery of safe abortion care by facilitating service provision all health facilities currently providing postabortion care. CONCLUSIONS SAC provision is much lower than PAC provision overall, yet there are persistent gaps in capacity to deliver basic PAC at primary facilities. These results highlight a need for the Ghana Ministry of Health to improve the infrastructural capability of health facilities to provide comprehensive abortion care.
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Affiliation(s)
- Onikepe Owolabi
- Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY 10038 USA
- Vital Strategies, 100 Broadway, 4th Floor, New York, 10005 USA
| | - Taylor Riley
- Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY 10038 USA
| | - Easmon Otupiri
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Chelsea B. Polis
- Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY 10038 USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Roderick Larsen-Reindorf
- Department of Obstetrics & Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Quach A, Tosif S, Nababan H, Duke T, Graham SM, Were WM, Muzigaba M, Russell FM. Assessing the quality of care for children attending health facilities: a systematic review of assessment tools. BMJ Glob Health 2021; 6:bmjgh-2021-006804. [PMID: 34607894 PMCID: PMC8491295 DOI: 10.1136/bmjgh-2021-006804] [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: 07/03/2021] [Accepted: 09/09/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Assessing quality of healthcare is integral in determining progress towards equitable health outcomes worldwide. Using the WHO 'Standards for improving quality of care for children and young adolescents in health facilities' as a reference standard, we aimed to evaluate existing tools that assess quality of care for children. METHODS We undertook a systematic literature review of publications/reports between 2008 and 2020 that reported use of quality of care assessment tools for children (<15 years) in health facilities. Identified tools were reviewed against the 40 quality statements and 510 quality measures from the WHO Standards to determine the extent each tool was consistent with the WHO Standards. The protocol was registered in PROSPERO ID: CRD42020175652. RESULTS Nine assessment tools met inclusion criteria. Two hospital care tools developed by WHO-Europe and WHO-South-East Asia Offices had the most consistency with the WHO Standards, assessing 291 (57·1%) and 208 (40·8%) of the 510 quality measures, respectively. Remaining tools included between 33 (6·5%) and 206 (40·4%) of the 510 quality measures. The WHO-Europe tool was the only tool to assess all 40 quality statements. The most common quality measures absent were related to experience of care, particularly provision of educational, emotional and psychosocial support to children and families, and fulfilment of children's rights during care. CONCLUSION Quality of care assessment tools for children in health facilities are missing some key elements highlighted by the WHO Standards. The WHO Standards are, however, extensive and applying all the quality measures in every setting may not be feasible. A consensus of key indicators to monitor the WHO Standards is required. Existing tools could be modified to include priority indicators to strengthen progress reporting towards delivering quality health services for children. In doing so, a balance between comprehensiveness and practical utility is needed. PROSPERO REGISTRATION NUMBER CRD42020175652.
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Affiliation(s)
- Alicia Quach
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia .,Asia Pacific Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Shidan Tosif
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Herfina Nababan
- Health System Strengthening Unit, World Health Organisation Country Office for Indonesia, Jakarta, Indonesia
| | - Trevor Duke
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Stephen M Graham
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,International Child Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Wilson M Were
- Maternal, Newborn, Child and Adolescent Health and Ageing Department, World Health Organization, Geneva, Switzerland
| | - Moise Muzigaba
- Maternal, Newborn, Child and Adolescent Health and Ageing Department, World Health Organization, Geneva, Switzerland
| | - Fiona M Russell
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,Asia Pacific Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
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Stierman EK, Ahmed S, Shiferaw S, Zimmerman LA, Creanga AA. Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia. BMJ Glob Health 2021; 6:e006698. [PMID: 34610906 PMCID: PMC8493923 DOI: 10.1136/bmjgh-2021-006698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards. METHODS We used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume. RESULTS Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices. CONCLUSION SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.
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Affiliation(s)
- Elizabeth K Stierman
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Saifuddin Ahmed
- Department of Population, Family And Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Oromia, Ethiopia
| | - Linnea A Zimmerman
- Department of Population, Family And Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Khanna M, Loevinsohn B, Pradhan E, Fadeyibi O, McGee K, Odutolu O, Fritsche GB, Meribole E, Vermeersch CMJ, Kandpal E. Decentralized facility financing versus performance-based payments in primary health care: a large-scale randomized controlled trial in Nigeria. BMC Med 2021; 19:224. [PMID: 34544415 PMCID: PMC8452448 DOI: 10.1186/s12916-021-02092-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. METHODS We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. RESULTS PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual (p<0.01). PBF and DFF were more effective than business-as-usual for Penta3 (p<0.05 and p<0.01, respectively); PBF also for mCPR (p<0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual (p<0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF (p<0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution (p<0.05). CONCLUSIONS Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. TRIAL REGISTRATION ClinicalTrials.gov NCT03890653 ; May 8, 2017. Retrospectively registered.
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Affiliation(s)
| | - Benjamin Loevinsohn
- The Global Fund, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - Elina Pradhan
- Health, Nutrition and Population, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Opeyemi Fadeyibi
- Health, Nutrition and Population, The World Bank, 102 Yakubu Gowon Cres, Asokoro, Abuja, Nigeria
| | - Kevin McGee
- Development Data Group, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Oluwole Odutolu
- Health, Nutrition and Population, The World Bank, 102 Yakubu Gowon Cres, Asokoro, Abuja, Nigeria
| | - Gyorgy Bela Fritsche
- Health, Nutrition and Population, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Emmanuel Meribole
- The Federal Ministry of Health of Nigeria, New Federal Secretariat Complex, Phase III, Ahmadu Bello Way, Central Business District, FCT, Abuja, Nigeria
| | - Christel M J Vermeersch
- Health, Nutrition and Population, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA
| | - Eeshani Kandpal
- Development Data Group, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA. .,Development Research Group, The World Bank, 1818 H Street NW, Washington, DC, 20433, USA.
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Understanding Women's Choices: How Women's Perceptions of Quality of Care Influences Place of Delivery in a Rural Sub-County in Kenya. A Qualitative Study. Matern Child Health J 2021; 25:1787-1797. [PMID: 34529225 DOI: 10.1007/s10995-021-03214-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Maternal mortality is still unacceptably high in Kenya. The Kenyan Government introduced a free maternity service to overcome financial barriers to access. This policy led to a substantial increase in women's delivery options. This increase in coverage might have led to a reduction in quality of care. This study explores women's perceptions of quality of delivery services in the context of the free policy and how the perceptions lead to the choice of a place for delivery. METHODS Our study site was Naivasha sub-County in Kenya, a rural context, whose geography encompasses pastoralists, rural agrarian, and high population density informal settlements near flower farms. Women from this area are from the lowest wealth quintile in Kenya. We conducted a qualitative study to explore the women's perceptions of quality of care based on their experiences during maternity care. The participants were women of reproductive age (18-49 years) attending antenatal care clinics at six health facilities in the sub-county. Six focus group discussions with 55 respondents were used. For inclusion, the women needed to have delivered a baby within the six months preceding the study. Interviews were recorded with consent, translated and transcribed. The interviews were analyzed using a thematic content approach. RESULTS Four broad themes that determined the choice of health facility for delivery were identified: women's perceptions of clinical quality of care; the cost of delivery; distance to the health facility and management of primary health facilities. An unexpected theme was the presence of home deliveries amongst pastoralist women. These findings suggest that in this setting both process and structural dimensions of quality of care and financial and physical accessibility influence women's choices for place of delivery. CONCLUSION This study expands our understanding of how women make choices regarding place of delivery. Understanding women's perceptions can provide useful insights to policy makers and facility managers on providing high quality patient centered maternity care necessary to sustain the increased utilization of maternity services at health facilities under the free maternity policy and further reductions in maternal mortality.
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Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study. BMJ Glob Health 2021; 6:bmjgh-2020-004406. [PMID: 34475022 PMCID: PMC8413881 DOI: 10.1136/bmjgh-2020-004406] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION As childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs). METHODS A multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant. RESULTS 1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis. CONCLUSION Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.
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King JJC, Powell-Jackson T, Makungu C, Spieker N, Risha P, Mkopi A, Goodman C. Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trial. Lancet Glob Health 2021; 9:e1262-e1272. [PMID: 34363766 PMCID: PMC8370880 DOI: 10.1016/s2214-109x(21)00228-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Quality of care is consistently shown to be inadequate in health-care settings in many low-income and middle-income countries, including in private facilities, which are rapidly growing in number but often do not have effective quality stewardship mechanisms. The SafeCare programme aims to address this gap in quality of care, using a standards-based approach adapted to low-resource settings, involving assessments, mentoring, training, and access to loans, to improve clinical quality and facility business performance. We assessed the effect of the SafeCare programme on quality of patient care in faith-based and private for-profit facilities in Tanzania. METHODS In this cluster-randomised controlled trial, health facilities were eligible if they were dispensaries, health centres, or hospitals in the faith-based or private for-profit sectors in Tanzania. We randomly assigned facilities (1:1) using computer-generated stratified randomisation to receive the full SafeCare package (intervention) or an assessment only (control). Implementing staff and participants were masked to outcome measurement and the primary outcomes were measured by fieldworkers who had no knowledge of the study group allocation. The primary outcomes were health worker compliance with infection prevention and control (IPC) practices as measured by observation of provider-patient interactions, and correct case management of undercover standardised patients at endline (after a minimum of 18 months). Analyses were by modified intention to treat. The trial is registered with ISRCTN, ISRCTN93644888. FINDINGS Between March 7 and Nov 30, 2016, we enrolled and randomly assigned 237 health facilities to the intervention (n=118) or control (n=119). Nine facilities (seven intervention facilities and two control facilities) closed during the trial and were not included in the analysis. We observed 29 608 IPC indications in 5425 provider-patient interactions between Feb 7 and April 5, 2018. Health facilities received visits from 909 standardised patients between May 3 and June 12, 2018. Intervention facilities had a 4·4 percentage point (95% CI 0·9-7·7; p=0.015) higher mean SafeCare standards assessment score at endline than control facilities. However, there was no evidence of a difference in clinical quality between intervention and control groups at endline. Compliance with IPC practices was observed in 8181 (56·9%) of 14 366 indications in intervention facilities and 8336 (54·7%) of 15 242 indications in control facilities (absolute difference 2·2 percentage points, 95% CI -0·2 to -4·7; p=0·071). Correct management occurred in 120 (27·0%) of 444 standardised patients in the intervention group and in 136 (29·2%) of 465 in the control group (absolute difference -2·8 percentage points, 95% CI -8·6 to -3·1; p=0·36). INTERPRETATION SafeCare did not improve clinical quality as assessed by compliance with IPC practices and correct case management. The absence of effect on clinical quality could reflect a combination of insufficient intervention intensity, insufficient links between structural quality and care processes, scarcity of resources for quality improvement, and inadequate financial and regulatory incentives for improvement. FUNDING UK Health Systems Research Initiative (Medical Research Council, Economic and Social Research Council, UK Department for International Development, Global Challenges Research Fund, and Wellcome Trust).
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Affiliation(s)
| | | | | | | | - Peter Risha
- PharmAccess Tanzania, Dar es Salaam, Tanzania
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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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Effect of health systems context on infant and child mortality in sub-Saharan Africa from 1995 to 2015, a longitudinal cohort analysis. Sci Rep 2021; 11:16263. [PMID: 34381150 PMCID: PMC8357794 DOI: 10.1038/s41598-021-95886-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 07/29/2021] [Indexed: 11/28/2022] Open
Abstract
Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday. Most deaths are preventable or avoidable through interventions delivered in the primary healthcare system. However, evidence regarding the impact of health system characteristics on child survival is sparse. We assembled a retrospective cohort of > 250,000 children in seven countries in sub-Saharan Africa. We described their health service context at the subnational level using standardized surveys and employed parametric survival models to estimate the effect of three major domains of health services—quality, access, and cost—on infant and child survival, after adjusting for child, maternal, and household characteristics. Between 1995 and 2015 we observed 13,629 deaths in infants and 5149 in children. In fully-adjusted models, the largest effect sizes were related to fees for services. Immunization fees were correlated with poor child survival (HR = 1.20, 95% CI 1.12–1.28) while delivery fees were correlated with poor infant survival (HR = 1.11, 95% CI 1.01–1.21). Accessibility of facilities and greater concentrations of private facilities were associated with improved infant and child survival. The proportion of facilities with a doctor was correlated with increased risk of death in children and infants. We quantify the impact of health service environment on survival up to five years of age. Reducing health care costs and improving the accessibility of health facilities should remain a priority for improving infant and child survival. In the absence of these fundamental investments, more specialized interventions may not achieve their desired impact.
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