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      Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries

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      PLoS Medicine
      Public Library of Science

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          Abstract

          Background

          It is increasingly apparent that access to healthcare without adequate quality of care is insufficient to improve population health outcomes. We assess whether the most commonly measured attribute of health facilities in low- and middle-income countries (LMICs)—the structural inputs to care—predicts the clinical quality of care provided to patients.

          Methods and findings

          Service Provision Assessments are nationally representative health facility surveys conducted by the Demographic and Health Survey Program with support from the US Agency for International Development. These surveys assess health system capacity in LMICs. We drew data from assessments conducted in 8 countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda. The surveys included an audit of facility infrastructure and direct observation of family planning, antenatal care (ANC), sick-child care, and (in 2 countries) labor and delivery. To measure structural inputs, we constructed indices that measured World Health Organization-recommended amenities, equipment, and medications in each service. For clinical quality, we used data from direct observations of care to calculate providers’ adherence to evidence-based care guidelines. We assessed the correlation between these metrics and used spline models to test for the presence of a minimum input threshold associated with good clinical quality. Inclusion criteria were met by 32,531 observations of care in 4,354 facilities. Facilities demonstrated moderate levels of infrastructure, ranging from 0.63 of 1 in sick-child care to 0.75 of 1 for family planning on average. Adherence to evidence-based guidelines was low, with an average of 37% adherence in sick-child care, 46% in family planning, 60% in labor and delivery, and 61% in ANC. Correlation between infrastructure and evidence-based care was low (median 0.20, range from −0.03 for family planning in Senegal to 0.40 for ANC in Tanzania). Facilities with similar infrastructure scores delivered care of widely varying quality in each service. We did not detect a minimum level of infrastructure that was reliably associated with higher quality of care delivered in any service. These findings rely on cross-sectional data, preventing assessment of relationships between structural inputs and clinical quality over time; measurement error may attenuate the estimated associations.

          Conclusion

          Inputs to care are poorly correlated with provision of evidence-based care in these 4 clinical services. Healthcare workers in well-equipped facilities often provided poor care and vice versa. While it is important to have strong infrastructure, it should not be used as a measure of quality. Insight into health system quality requires measurement of processes and outcomes of care.

          Abstract

          In a cross-sectional study of 4,300 facilities in 8 countries, Hannah Leslie and colleagues examine the association between infrastructure and observed quality of care in 4 healthcare services.

          Author summary

          Why was this study done?
          • Improved quality of care is increasingly recognized as a necessary step towards achievement of better population health outcomes in low- and middle-income countries.

          • Much of the current measurement effort focuses on inputs to care.

          • It is not known whether such measures provide insight on the quality of care delivered.

          What did the researchers do and find?
          • We quantified facility infrastructure using international guidelines for readiness in each service applied to health facility audits in 8 countries; we defined quality of clinical care based on adherence to evidence-based protocols measured using direct observation in the same facility assessments.

          • We calculated the level and correlation of infrastructure and average adherence to guidelines for each of 4 clinical services in this sample: family planning (1,842 facilities), antenatal care (1,407 facilities), delivery care (227 facilities), and sick-child care (4,038 facilities).

          • Infrastructure scored higher than observed clinical quality in each service, and the correlation between the 2 was modest.

          What do these findings mean?
          • Assessment of infrastructure is insufficient to estimate the quality of care delivered to women and children in need.

          • Measurement priorities should be reassessed to support more timely information for quality improvement purposes and more pertinent information on the quality of care delivered for monitoring and comparison.

          Related collections

          Most cited references21

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          Is Open Access

          Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment

          Objective To describe the Service Availability and Readiness Assessment (SARA) and the results of its implementation in six countries across three continents. Methods The SARA is a comprehensive approach for assessing and monitoring health service availability and the readiness of facilities to deliver health-care interventions, with a standardized set of indicators that cover all main programmes. Standardized data-collection instruments are used to gather information on a defined set of selected tracer items from public and private health facilities through a facility sample survey or census. Results from assessments in six countries are shown. Findings The results highlight important gaps in service delivery that are obstacles to universal access to health services. Considerable variation was found within and across countries in the distribution of health facility infrastructure and workforce and in the types of services offered. Weaknesses in laboratory diagnostic capacities and gaps in essential medicines and commodities were common across all countries. Conclusion The SARA fills an important information gap in monitoring health system performance and universal health coverage by providing objective and regular information on all major health programmes that feeds into country planning cycles.
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            Outpatient process quality evaluation and the Hawthorne Effect.

            We examine the evidence that the behavior of clinicians is impacted by the fact that they are being observed by a research team. Data on the quality of care provided by clinicians in Arusha region of Tanzania show a marked fall in quality over time as new patients are consulted. By conducting detailed interviews with patients who consulted both before and after our research team arrived we are able to show strong evidence of the Hawthorne effect. Patient-reported quality is steady before we arrive, rises significantly (by 13 percentage points) at the moment we arrive and then falls steadily thereafter. We show that quality after we arrive begins to look similar to quality before we arrived between the 10th and 15th consultations. Implications for quality measurement and policy are discussed.
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              Fundamental elements of the quality of care: a simple framework.

              J Bruce (2015)
              This article argues for attention to a neglected dimension of family planning services--their quality. A framework for assessing quality from the client's perspective is offered, consisting of six parts (choice of methods, information given to clients, technical competence, interpersonal relations, follow-up and continuity mechanisms, and the appropriate constellation of services). The literature is reviewed regarding evidence that improvements in these various dimensions of care result in gains at the individual level; an even scarcer body of literature is reviewed for evidence of gains at the level of program efficiency and impact. A concluding section discusses how to make practical use of the framework and distinguishes three vantage points from which to view quality: the structure of the program, the service-giving process itself, and the outcome of care, particularly with respect to individual knowledge, behavior, and satisfaction with services.
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                Author and article information

                Contributors
                Role: Data curationRole: Formal analysisRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                12 December 2017
                December 2017
                : 14
                : 12
                : e1002464
                Affiliations
                [001]Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
                London School of Hygiene and Tropical Medicine, UNITED KINGDOM
                Author notes

                I have read the journal's policy and the authors of this manuscript have the following competing interests: MEK is a member of the Editorial Board of PLOS Medicine.

                Author information
                http://orcid.org/0000-0002-7464-3645
                http://orcid.org/0000-0002-9549-8432
                Article
                PMEDICINE-D-17-02302
                10.1371/journal.pmed.1002464
                5726617
                29232377
                b304cdcb-ad3d-408f-9d79-f78e0902e911
                © 2017 Leslie et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 30 June 2017
                : 25 October 2017
                Page count
                Figures: 3, Tables: 3, Pages: 16
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Award ID: OPP1161450
                Award Recipient : Margaret E. Kruk
                Funded by: McLennan Family Fund at Harvard TH Chan School of Public Health
                Award Recipient : Margaret E. Kruk
                This work was partially supported by the Bill & Melinda Gates Foundation ( http://www.gatesfoundation.org/) grant OPP1161450 (MEK) and the McLennan Family Fund at the Harvard T.H. Chan School of Public Health ( https://www.hsph.harvard.edu/research-strategy-and-development/funding-announcements/internal-funding/mclennan-family-fund-deans-challenge-grant-program-2/) (MEK). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Antenatal Care
                Medicine and Health Sciences
                Health Care
                Quality of Care
                Medicine and Health Sciences
                Public and Occupational Health
                Global Health
                Engineering and Technology
                Equipment
                People and Places
                Geographical Locations
                Africa
                Kenya
                People and Places
                Geographical Locations
                Africa
                Malawi
                People and Places
                Geographical Locations
                Africa
                Rwanda
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Custom metadata
                The SPA files used in this analysis are available for download from the Demographic and Health Surveys (DHS) Program website. These data are publicly available but require permission from the DHS Program. DHS registration can be obtained at the following website: https://dhsprogram.com/data/Access-Instructions.cfm.

                Medicine
                Medicine

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