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Maiba J, Singh NS, Cassidy R, Mtei G, Borghi J, Kapologwe NA, Binyaruka P. Assessment of strategic healthcare purchasing and financial autonomy in Tanzania: the case of results-based financing and health basket fund. Front Public Health 2024; 11:1260236. [PMID: 38283298 PMCID: PMC10811957 DOI: 10.3389/fpubh.2023.1260236] [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: 07/17/2023] [Accepted: 10/03/2023] [Indexed: 01/30/2024] Open
Abstract
Background Low-and middle-income countries (LMICs) are implementing health financing reforms toward Universal Health Coverage (UHC). In Tanzania direct health facility financing of health basket funds (DHFF-HBF) scheme was introduced in 2017/18, while the results-based financing (RBF) scheme was introduced in 2016. The DHFF-HBF involves a direct transfer of pooled donor funds (Health Basket Funds, HBF) from the central government to public primary healthcare-PHC (including a few selected non-public PHC with a service agreement) facilities bank accounts, while the RBF involves paying providers based on pre-defined performance indicators or targets in PHC facilities. We consider whether these two reforms align with strategic healthcare purchasing principles by describing and comparing their purchasing arrangements and associated financial autonomy. Methods We used document review and qualitative methods. Key policy documents and articles related to strategic purchasing and financial autonomy were reviewed. In-depth interviews were conducted with health managers and providers (n = 31) from 25 public facilities, health managers (n = 4) in the Mwanza region (implementing DHFF-HBF and RBF), and national-level stakeholders (n = 2). In this paper, we describe and compare DHFF-HBF and RBF in terms of four functions of strategic purchasing (benefit specification, contracting, payment method, and performance monitoring), but also compare the degree of purchaser-provider split and financial autonomy. Interviews were recorded, transcribed verbatim, and analyzed using a thematic framework approach. Results The RBF paid facilities based on 17 health services and 18 groups of quality indicators, whilst the DHFF-HBF payment accounts for performance on two quality indicators, six service indicators, distance from district headquarters, and population catchment size. Both schemes purchased services from PHC facilities (dispensaries, health centers, and district hospitals). RBF uses a fee-for-service payment adjusted by the quality of care score method adjusted by quality of care score, while the DHFF-HBF scheme uses a formula-based capitation payment method with adjustors. Unlike DHFF-HBF which relies on an annual general auditing process, the RBF involved more detailed and intensive performance monitoring including data before verification prior to payment across all facilities on a quarterly basis. RBF scheme had a clear purchaser-provider split arrangement compared to a partial arrangement under the DHFF-HBF scheme. Study participants reported that the RBF scheme provided more autonomy on spending facility funds, while the DHFF-HBF scheme was less flexible due to a budget ceiling on specific spending items. Conclusion Both RBF and DHFF-HBF considered most of the strategic healthcare purchasing principles, but further efforts are needed to strengthen the alignment towards UHC. This may include further strengthening the data verification process and spending autonomy for DHFF-HBF, although it is important to contain costs associated with verification and ensuring public financial management around spending autonomy.
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Affiliation(s)
- John Maiba
- Department of Health System, Impact Evaluation, and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Neha S. Singh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rachel Cassidy
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Geneva Centre of Humanitarian Studies, University of Geneva, Geneva, Switzerland
| | - Gemini Mtei
- Abt Associates Inc., USAID Public Sector Systems Strengthening (PS3+) Project, Dar es Salaam, Tanzania
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ntuli A. Kapologwe
- President's Office, Regional Administration, and Local Government Tanzania – (PO-RALG), Dodoma, Tanzania
| | - Peter Binyaruka
- Department of Health System, Impact Evaluation, and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
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Massele A, Rogers AM, Gabriel D, Mayanda A, Magoma S, Cook A, Chigome A, Lorenzetti G, Meyer JC, Moore CE, Godman B, Minzi O. A Narrative Review of Recent Antibiotic Prescribing Practices in Ambulatory Care in Tanzania: Findings and Implications. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2195. [PMID: 38138298 PMCID: PMC10745081 DOI: 10.3390/medicina59122195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
Background and objectives: There are concerns with the current prescribing practices of antibiotics in ambulatory care in Tanzania, including both the public and private sectors. These concerns need to be addressed as part of the national action plan (NAP) of Tanzania to reduce rising antimicrobial resistance (AMR) rates. Issues and concerns include high rates of prescribing of antibiotics for essentially self-limiting conditions. Consequently, there is a need to address this. As a result, the aims of this narrative review were to comprehensively summarize antibiotic utilization patterns particularly in ambulatory care and their rationale in Tanzania and to suggest ways forward to improve future prescribing practices. Materials and Methods: We undertook a narrative review of recently published studies and subsequently documented potential activities to improve future prescribing practices. Potential activities included instigating quality indicators and antimicrobial stewardship programs (ASPs). Results: Published studies have shown that antibiotics are being excessively prescribed in ambulatory care in Tanzania, in up to 95% to 96.3% of presenting cases depending on the sector. This is despite concerns with their appropriateness. High rates of antibiotic prescribing are not helped by variable adherence to current treatment guidelines. There have also been concerns with extensive prescribing of 'Watch' antibiotics in the private sector. Overall, the majority of antibiotics prescribed across the sectors, albeit inappropriately, were typically from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. The inappropriate prescribing of antibiotics in ambulatory care is linked to current knowledge regarding antibiotics, AMR, and ASPs among both prescribers and patients. Recommended activities for the future include improved education for all groups, the instigation of updated quality indicators, and the regular monitoring of prescribing practices against agreed-upon guidelines and indicators. Education for healthcare professionals on ASPs should start at undergraduate level and continue post qualification. Community advocacy on the rational use of antibiotics should also include social media activities to dispel misinformation. Conclusion: The quality of current prescribing practices of antibiotics in ambulatory care is sub-optimal in Tanzania. This needs to be urgently addressed.
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Affiliation(s)
- Amos Massele
- Department of Clinical Pharmacology and Therapeutics, Hubert Kairuki Memorial University, 70 Chwaku Road Mikocheni, Dar Es Salaam P.O. Box 65300, Tanzania
| | - Anastasia Martin Rogers
- Department of Microbiology and Parasitology, Faculty of Medicine, Hubert Kairuki Memorial University, 70 Chwaku Road Mikocheni, Dar Es Salaam P.O. Box 65300, Tanzania; (A.M.R.); (D.G.); (A.M.)
| | - Deogratias Gabriel
- Department of Microbiology and Parasitology, Faculty of Medicine, Hubert Kairuki Memorial University, 70 Chwaku Road Mikocheni, Dar Es Salaam P.O. Box 65300, Tanzania; (A.M.R.); (D.G.); (A.M.)
| | - Ashura Mayanda
- Department of Microbiology and Parasitology, Faculty of Medicine, Hubert Kairuki Memorial University, 70 Chwaku Road Mikocheni, Dar Es Salaam P.O. Box 65300, Tanzania; (A.M.R.); (D.G.); (A.M.)
| | - Sarah Magoma
- Department of Infectious Diseases, Faculty of Medicine, University of Dodoma, Dodoma P.O. Box 582, Tanzania;
| | - Aislinn Cook
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St. George’s University of London, London SW17 0RE, UK; (A.C.); (G.L.); (C.E.M.)
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX1 2JD, UK
| | - Audrey Chigome
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, South Africa (J.C.M.)
| | - Giulia Lorenzetti
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St. George’s University of London, London SW17 0RE, UK; (A.C.); (G.L.); (C.E.M.)
| | - Johanna C. Meyer
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, South Africa (J.C.M.)
- South African Vaccination and Immunisation Centre, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, South Africa
| | - Catrin E. Moore
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St. George’s University of London, London SW17 0RE, UK; (A.C.); (G.L.); (C.E.M.)
| | - Brian Godman
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, South Africa (J.C.M.)
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, United Nations Rd, Dar Es Salaam P.O. Box 65013, Tanzania;
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Kinyenje E, Ngowi RR, Msigwa YS, Hokororo JC, Yahya TA, German CJ, Mawazo A, Mohamed MA, Nassoro OA, Degeh MM, Bahegwa RP, Marandu LE, Mwaisengela SM, Mwanginde LW, Makala R, Eliakimu ES. Status of countrywide laboratory services quality and capacity in primary healthcare facilities in Tanzania: Findings from Star Rating Assessment. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001489. [PMID: 37851603 PMCID: PMC10584114 DOI: 10.1371/journal.pgph.0001489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
Accurate disease diagnosis relies on a well-organized and reliable laboratory system. This study assesses the quality of laboratory services in Tanzania based on the nationwide Star Rating Assessment (SRA) of Primary Healthcare (PHC) facilities conducted in 2017/18. This cross-sectional study utilized secondary data from all the country's PHC facilities stored in the SRA database. Laboratory service quality was assessed by aggregating scores as percentages of the maximum achievable score across various indicators: dedicated laboratory department/room, adequate equipment, staffing levels, adherence to testing protocols, establishment of turnaround times, internal and external quality controls, and safety and supplies management. Scores equal to or exceeding 80% were deemed compliant. Multiple linear regression was used to determine the influence of facility characteristics (level, ownership, location, staffing) on quality scores, with statistical significance set at p < 0.05. The study included 6,663 PHC facilities (85.9% dispensaries, 11% health centers, 3.2% hospital-level-1), with the majority being public (82.3% vs. 17.7%) and located in rural areas (77.1% vs. 22.9%). On average, facilities scored 30.8% (SD = 35.7), and only 26.6% met staffing requirements. Compliance with quality standards was higher in private (63% vs. 19%, p<0.001) and urban facilities (62% vs. 16%, p<0.001). More than half of the facilities did not meet either of the eight quality indicators. Quality was positively linked to staffing compliance (Beta = 5.770) but negatively impacted by dispensaries (Beta = -6.342), rural locations (Beta = -0.945), and public ownership (Beta = -1.459). A score of 30% falls significantly short of the national target of 80%. Improving laboratory staffing levels at PHC facilities could improve the quality of laboratory services, especially in public facilities that are based in rural areas. There is a need to further strengthen laboratory services in PHC facilities to ensure the quality of laboratory services and clients' satisfaction.
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Affiliation(s)
- Erick Kinyenje
- Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania
| | - Ruth R. Ngowi
- Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania
| | | | | | | | | | - Akili Mawazo
- Department of Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed A. Mohamed
- Tanzania Field Epidemiology and Laboratory Training Programme (TFELTP), Dar es Salaam, Tanzania
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Omary A. Nassoro
- Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania
| | - Mbwana M. Degeh
- Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania
| | | | - Laura E. Marandu
- Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania
| | | | | | - Robert Makala
- Regional Administrative Secretary’s Office—Regional Health Management Team, Manyara, Tanzania
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Marandu LE, Masika GM. Healthcare workers' level of adherence to infection prevention and control and its impact on puerperal and neonatal sepsis among delivering women and neonates in Central Tanzania: a protocol for a prospective cohort study. BMJ Open 2023; 13:e066701. [PMID: 36918240 PMCID: PMC10016239 DOI: 10.1136/bmjopen-2022-066701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Delivering women and neonates are at a great risk of acquiring infections due to a lack of adherence to infection prevention and control (IPC), a low level of immunity and extended exposure to care procedures that can lead to infections. This prospective cohort study aims to assess the level of adherence to IPC among healthcare workers and its impact on puerperal and neonatal sepsis in the Dodoma region. METHODS AND ANALYSIS The level of adherence to IPC is examined cross-sectionally among healthcare workers (HCWs) in contact with delivering women and their neonates. A prospective cohort approach is used to assess the level of exposure of 294 delivering women and their neonates to poor hygienic practices of HCWs through an observation checklist. Outcomes, including the incidence of puerperal and neonatal sepsis, are evaluated clinically 2 days later before discharge. Laboratory culture and sensitivity confirmatory tests of blood samples are done on positive cases. Data analysis for level of adherence to IPC practices, incidence of puerperal and neonatal sepsis, and relative risk among the exposed women and neonates will be performed. ETHICS AND DISSEMINATION The University of Dodoma Research Ethics Committee approved this study (ref no. MA.84/261/'A'/25). Findings of this study will be published in international peer-reviewed journals and disseminated at international conferences to the participating hospitals, the University of Dodoma and the Tanzanian Ministry of Health for informing practice and policy.
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Affiliation(s)
- Laura Edward Marandu
- Department of Clinical Nursing, The University of Dodoma, Dodoma, Tanzania, United Republic of
- Department of Health Quality Assurance, Ministry of Health, Dodoma, Tanzania, United Republic of
| | - Golden Mwakibo Masika
- Department of Clinical Nursing, School of Nursing and Public Health, The University of Dodoma, Dodoma, Tanzania, United Republic of
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Kamala SR, Julius Z, Kosia EM, Manzi F. Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns. PLoS One 2022; 17:e0269151. [PMID: 36409741 PMCID: PMC9678323 DOI: 10.1371/journal.pone.0269151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/03/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania. METHODS A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs). RESULTS About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania. CONCLUSION Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs.
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Affiliation(s)
- Serveus Ruyobya Kamala
- Department of Health Systems, Policy, Economic Evaluations, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
- Department of Global Health and Bio-Medical Sciences (GHBM), School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
- Department of Health, Mtwara Regional Secretariat, Mtwara, Tanzania
- * E-mail:
| | - Zamoyoni Julius
- Department of Health Systems, Policy, Economic Evaluations, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Efraim M. Kosia
- Department of Global Health and Bio-Medical Sciences (GHBM), School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
| | - Fatuma Manzi
- Department of Health Systems, Policy, Economic Evaluations, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
- Department of Global Health and Bio-Medical Sciences (GHBM), School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
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Tomblin Murphy G, Mtey G, Nyamtema A, LeBlanc J, Rigby J, Abel Z, Mselle LT. Building leadership and managerial capacity for maternal and newborn health services. BMC Health Serv Res 2022; 22:1129. [PMID: 36071415 PMCID: PMC9450380 DOI: 10.1186/s12913-022-08448-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Strengthening leadership and management is important for building an effective and efficient health system. This paper presents the findings from a L&M capacity building initiative which was implemented as part of a larger study aimed at improving maternal and newborn outcomes within primary health facilities in the Morogoro, Tanzania. Methods The initiative, involving 30 stakeholders from 20 primary health facilities, 4 council health management teams and the regional health management team in the Morogoro region, provided leadership and managerial training through two 5-day in-person workshops, onsite mentoring, and e-learning modules. The initiative was evaluated using a pre-post design. Quantitative instruments included the ‘Big Results Now’ star-rating assessments and a team-developed survey for health providers/managers. The ‘Big Results Now’ star-rating assessments, conducted in 2018 (19 facilities) and 2021 (20 facilities), measured overall facility leadership and management capability, with comparisons of star-ratings from the two time-points providing indication of improvement. The survey was used to measure 3 key leadership indicators - team climate, role clarity/conflict and job satisfaction. The survey was completed by 97 respondents at baseline and 100 at follow up. Paired t-tests were used to examine mean score differences for each indicator. Triangulated findings from focus groups with 99 health providers and health management team members provided support and context for quantitative findings. Results Star-ratings increased in 15 (79%) of 19 facilities, with the number of facilities achieving the target of 3 plus stars increasing from 2 (10%) in 2018 to 10 (50%) in 2021, indicating improved organizational performance. From the survey, team climate, job satisfaction and role clarity improved across the facilities over the 3 project years. Focus group discussions related this improvement to the leadership and managerial capacity-building. Conclusion Improved leadership and managerial capacity in the participating health facilities and enhanced communication between the health facility, council and regional health management teams created a more supportive workplace environment, leading to enhanced teamwork, job satisfaction, productivity, and improved services for mothers and newborns. Leadership and managerial training at all levels is important for ensuring efficient and effective health service provision.
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Affiliation(s)
- Gail Tomblin Murphy
- Nova Scotia Health and Dalhousie University WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, 90 Lovett Lake Ct., Suite 201, Halifax, NS, B3S 0H6, Canada.
| | - Godfrey Mtey
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Angelo Nyamtema
- Tanzanian Training Centre for International Health, Ifakara, Tanzania.,St Francis University College of Health and Allied Sciences, Ifakara, Tanzania
| | - John LeBlanc
- Faculty of Medicine, Dalhousie University and IWK Health Centre, Halifax, NS, Canada
| | - Janet Rigby
- Nova Scotia Health and Dalhousie University WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, 90 Lovett Lake Ct., Suite 201, Halifax, NS, B3S 0H6, Canada
| | - Zabron Abel
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Lilian Teddy Mselle
- School of Nursing, Muhimbili University for Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
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Clarke‐Deelder E, Eliakimu E, Mbatia R, Bohren MA, Mashasi I, Larson E. Measuring user experience of care among caregivers of sick children: validation and descriptive analysis in a sample of 75 health facilities in rural Tanzania. Trop Med Int Health 2022; 27:317-329. [DOI: 10.1111/tmi.13730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Emma Clarke‐Deelder
- Department of Epidemiology and Public Health Swiss Tropical and Public Health Institute Basel Switzerland
| | - Eliudi Eliakimu
- Health Quality Assurance Unit Ministry of Health, Community Development Gender, Elderly and Children Dodoma Tanzania
| | | | - Meghan A. Bohren
- Gender and Women’s Health Unit Centre for Health Equity School of Population and Global Health University of Melbourne Melbourne Australia
| | - Irene Mashasi
- Management and Development for Health Dar es Salaam Tanzania
| | - Elysia Larson
- Department of Obstetrics and Gynecology Beth Israel Deaconess Medical Center and Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School Boston USA
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Moyer CA, Waiswa P. In-country data will illuminate under-5 mortality disparities. Lancet 2021; 398:821-822. [PMID: 34416194 DOI: 10.1016/s0140-6736(21)01110-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/07/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Cheryl A Moyer
- Departments of Learning Health Sciences and Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI 48109-2054, USA.
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda; Global Public Health, Karolinska Institute, Stockholm, Sweden
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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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Roder-DeWan S, Yahya T. Stepwise accreditation in Tanzania: no impact on process quality. LANCET GLOBAL HEALTH 2021; 9:e1185-e1186. [PMID: 34363767 DOI: 10.1016/s2214-109x(21)00286-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 06/09/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - Talhiya Yahya
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
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