Anna D Gage

Training and supervision did not meaningfully improve quality of care for pregnant women or sick children in sub-Saharan Africa

In-service training courses and supportive supervision of health workers are among the most common interventions to improve the quality of health care in low- and middle-income countries. Despite extensive investment from donors, evaluations of the long-term effect of these two interventions are scarce. We used nationally representative surveys of health systems in seven countries in sub-Saharan Africa to examine the association of in-service training and supervision with provider quality in antenatal and sick child care. The results of our analysis showed that observed quality of care was poor, with fewer than half of evidence-based actions completed by health workers, on average. In-service training and supervision were associated with quality of sick child care; they were associated with quality of antenatal care only when provided jointly. All associations were modest-at most, improvements related to interventions were equivalent to 2 additional provider actions out of the 18-40 actions expected per visit. In-service training and supportive supervision as delivered were not sufficient to meaningfully improve the quality of care in these countries. Greater attention to the quality of health professional education and national health system performance will be required to provide the standard of health care that patients deserve.

Assessing the quality of primary care in Haiti

Abstract Objective To develop a composite measure of primary care quality and apply it to Haiti’s primary care system. Methods Using the Primary Health Care Performance Initiative’s framework, we defined four domains of primary care service delivery: (i) accessible care; (ii) effective service delivery; (iii) management and organization; and (iv) primary care functions. We gave each primary care facility in Haiti a quality score for each domain and overall, with poor, fair and good quality indicated by scores of 0.00–0.49, 0.50–0.74 and 0.75–1.00, respectively. We quantified access and effective access to primary care as the proportions of the population within 5 km of any primary care facility and a good facility, respectively. Findings Of the 786 primary care facilities in Haiti in 2013, only 332 (43%) facilities were classified as good for accessible care. Fewer facilities were classified as good in the domains of effective service delivery (30; 4%), management and organization (91; 12%) and primary care functions (43; 5%). Although about 91% of the population lived within 5 km of a primary care facility, only an estimated 23% of the entire population – including just 5% of the rural population – had access to primary care of good quality. Conclusion Despite an extensive network of health facilities, a minority of Haitians had access to a primary care facility of good quality. Such facilities were especially scarce in rural areas. Similar systematic analyses of the quality of primary care could inform national efforts to strengthen health systems.

Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries

Summary Background Universal health coverage has been proposed as a strategy to improve health in low-income and middle-income countries (LMICs). However, this is contingent on the provision of good-quality health care. We estimate the excess mortality for conditions targeted in the Sustainable Development Goals (SDG) that are amenable to health care and the portion of this excess mortality due to poor-quality care in 137 LMICs, in which excess mortality refers to deaths that could have been averted in settings with strong health systems. Methods Using data from the 2016 Global Burden of Disease study, we calculated mortality amenable to personal health care for 61 SDG conditions by comparing case fatality between each LMIC with corresponding numbers from 23 high-income reference countries with strong health systems. We used data on health-care utilisation from population surveys to separately estimate the portion of amenable mortality attributable to non-utilisation of health care versus that attributable to receipt of poor-quality care. Findings 15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care. Poor quality of health care was a major driver of excess mortality across conditions, from cardiovascular disease and injuries to neonatal and communicable disorders. Interpretation Universal health coverage for SDG conditions could avert 8·6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems. Funding Bill & Melinda Gates Foundation.

Does quality influence utilization of primary health care? Evidence from Haiti

BackgroundExpanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti.MethodsWe constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery.ResultsFacilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure.ConclusionsPoor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.

Can investment in quality drive use? A cluster-randomised controlled study in rural Tanzania

Abstract Background Reduction in maternal and neonatal mortality requires womens use of high-quality facilities for childbirth. Evidence that quality influences womens selection of place of delivery suggests that an investment in quality may increase use of facilities for childbirth. We assessed the impact of a quality improvement project on facility use for childbirth among women in Tanzania. Methods Of 24 government-managed primary care clinics in Pwani Region, Tanzania, we randomly selected 12 to receive an intervention consisting of: training, supportive supervision, infrastructure support, and peer outreach. The cluster was defined as the health clinic and the villages assigned to its catchment area by the ward. We collected household surveys of women living within the catchment area of each clinic with a birth in the past year at baseline (February–April 2012) and endline (January–April 2016). Women reported the location of birth for each of their deliveries, including the facility name. The primary outcome was report of facility use for childbirth for their most recent birth. The effect of the intervention was assessed using difference-in-difference analysis. We conducted an exploratory secondary analysis among women least likely to use the health system—ie, those whose prior delivery was a home birth. We investigated three pathways from the intervention to increased facility use: improved obstetric quality, improved antenatal care (ANC) quality, and improved links between the health system and the community. Findings In the intervention clusters, 999 (71·7%) of 1393 women gave birth in a facility at baseline and 1165 (85·3%) of 1365 did so at endline. The corresponding figures for the control clusters were 1146 (72·3%) of 1586 at baseline and 1411 (81·1%) of 1739 at endline. The intervention thus led to an increase in facility births of 6·7 percentage points (95% CI 0·6–12·8). The intervention was substantially more successful in increasing use among women least likely to utilise the health system, giving a 18·3 percentage point increase (95% CI 10·1–26·6). Among the hypothesised mechanisms, the most likely pathway of effect was through ANC: the intervention led to an increase in ANC quality, with providers performing an additional 0·8 (95% CI 0·21–1·34) actions among the low-use population and 0·5 actions among the full population (95% CI −0·01 to 1·01). Interpretation The quality improvement intervention led to a modest increase in facility use for childbirth and a strong increase among women whose previous delivery was at home. Our analysis provides empirical evidence that investment in quality can increase health care use. In an environment of rising use, quality may be a mechanism for encouraging remaining non-system users to engage in the health system, playing a role in achieving universal health coverage. Funding US National Institutes of Health 1R01AI093182.