Search

Author(s): Todd P. Lewis 1, Neena R. Kapoor 1, Amit Aryal 2,3, Rodrigo Bazua-Lobato 1, Susanne Carai 4, Emma Clarke-Deelder 2, Kevin Croke 1, Rashmi Dayalu 1, Laura Espinoza-Pajuelo 5, [...]

Objective: The Mexican government has pursued multiple initiatives to improve healthcare coverage and financial protection. Yet, out-of-pocket health spending and use of private sector providers in Mexico remains high. In this paper, we sought to describe the characteristics of public and private healthcare users, describe recent visit quality across provider types, and to assess whether perceiving the public healthcare sector as poor quality is associated with private health sector use. Methods and findings: We analyzed the cross-sectional People's Voice Survey conducted from December 2022 to January 2023. We used Chi-square tests to compare contextual, individual, and need-for-care factors and ratings of most recent visits between users of public (social security and other public providers) and private sector providers (stand-alone private providers and providers adjacent to pharmacies). We used a multivariable Poisson regression model to assess associations between low ratings of public healthcare sources and the use of private care. Among the 811 respondents with a healthcare visit in the past year, 31.2% used private sources. Private healthcare users were more educated and had higher incomes than public healthcare users. Quality of most recent visit was rated more highly in private providers (70.2% rating the visit as excellent or very good for stand-alone private providers and 54.3% for pharmacy-adjacent doctors) compared to social security (41.6%) and other public providers (46.6%). Those who perceived public health institutions as low quality had a higher probability of seeking private healthcare. Conclusion: Users rated public care visits poorly relative to private care; at the population level, perceptions of poor quality care may drive private care use and hence out-of-pocket costs. Improving public healthcare quality is necessary to ensure universal health coverage. [ABSTRACT FROM AUTHOR]

Research Findings: Childcare provider stress and job satisfaction has been found to influence childcare quality in high-income contexts, but this phenomenon has yet to be studied in a low- or middle-income country. In 2019–2020, we tested the reliability and validity of the Child Care Center Work Environment Scale (CCCWES) with 416 childcare providers in Da Nang and Quang Nam provinces, Vietnam. We assessed content and face validity and utilized item information within each factor to refine the CCCWES. We assessed convergent validity by evaluating the association between the constructs and childcare quality. In this setting, the original 50-item scale could be shortened to a reliable and valid 22-item scale. The scale comprised two factors: workplace stress and job satisfaction. Workplace stress was negatively associated with childcare quality (β=-0.100,95%CI=(−0.198,0.003)). Job satisfaction was positively associated with childcare quality (β = 0.154,95%CI=(0.056,0.251)). Practice or Policy: There is a need to measure work-related stress and job satisfaction among childcare providers in order to appropriately target interventions to reduce stress and to optimize support. We offer programs a short-form instrument that reliably measures childcare providers' workplace stress and job satisfaction in Vietnam. [ABSTRACT FROM AUTHOR]

Objective To evaluate the service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Methods Using existing data from service provision assessments of the health systems of the 10 study countries, we calculated a service readiness index for each of 8443 health facilities. This index represents the percentage availability of 50 items that the World Health organization considers essential for providing health care. For our analysis we used 37-49 of the items on the list. We used linear regression to assess the independent explanatory power of four national and four facility- level characteristics on reported service readiness. Findings The mean values for the service readiness index were 77% for the 636 hospitals and 52% for the 7807 health centres/clinics. Deficiencies in medications and diagnostic capacity were particularly common. The readiness index varied more between hospitals and health centres/clinics in the same country than between them. There was weak correlation between national factors related to health financing and the readiness index. Conclusion Most health facilities in our study countries were insufficiently equipped to provide basic clinical care. If countries are to bolster health-system capacity towards achieving universal coverage, more attention needs to be given to within-country inequities. Objectif Evaluer la disponibilite des services dans les etablissements de sante du Bangladesh, d'Haiti, du Kenya, du Malawi, de Namibie, du Nepal, d'Ouganda, de Republique-Unie deTanzanie, du Rwanda et du Senegal. Methodes En nous appuyant sur les donnees existantes tirees de l'evaluation de la prestation des services dans les systemes de sante des 10 pays etudies, nous avons calcule un indice de disponibilite des services pour chacun des 8443 etablissements de sante. Cet indice correspond a la disponibilite en pourcentage de 50 elements que l'organisation mondiale de la Sante estime essentiels pour assurer les soins de sante. Dans le cadre de notre analyse, nous avons utilise entre 37 et 49 elements de la liste. Nous avons eu recours a une regression lineaire pour evaluer le pouvoir explicatif independant de quatre caracteristiques nationales et quatre caracteristiques au niveau des etablissements concernant la disponibilite des services etablie. Resultats Les valeurs moyennes de l'indice de disponibilite des services etaient de 77% pour les 636 hopitaux et de 52% pour les 7807 centres de sante/dispensaires. L'analyse a revele des insuffisances particulierement courantes en matiere de medicaments et de capacites de diagnostic. L'indice de disponibilite variait davantage entre les hopitaux et les centres de sante/dispensaires d'un meme pays qu'entre differents pays. Une faible correlation a ete constatee entre les facteurs nationaux lies au financement de la sante et l'indice de disponibilite. Conclusion La plupart des etablissements de sante des pays etudies n'etaient pas dotes d'equipements suffisants pour prodiguer les soins cliniques de base. Il est necessaire de preter davantage attention aux inegalites au sein des pays pour qu'ils renforcent les capacites de leur systeme de sante en vue d'assurer une couverture universelle. Objetivo Evaluar la disponibilidad del servicio de los centros sanitarios en Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, la Republica Unida de Tanzania, Rwanda, Senegal y Uganda. Metodos Usando los datos existentes de las evaluaciones sobre prestacion de servicios de sistemas sanitarios de los 10 paises de estudio, se ha calculado un indice de disponibilidad del servicio para cada uno de los 8443 centros sanitarios. El indice representa el porcentaje de disponibilidad de 50 elementos que la organizacion Mundial de la Salud considera esenciales para proporcionar atencion sanitaria. Para el analisis, se han utilizado entre 37 y 49 de los elementos de la lista. Se ha utilizado la regresion lineal para evaluar el poder independiente descriptivo de cuatro caracteristicas nacionales y cuatro a nivel del centro sobre la disponibilidad del servicio registrado. Resultados Los valores medios del indice de la disponibilidad del servicio fueron del 77% para los 636 hospitales y del 52% para los 7807 centros de salud/clinicas. Las deficiencias en los medicamentos y la capacidad de diagnostico fueron particularmente comunes. El indice de disponibilidad vario mas entre hospitales y centros de salud/clinicas en el mismo pais que entre paises. Existe una correlacion debil entre los factores nacionales relacionados con la financiacion sanitaria y el indice de disponibilidad. Conclusion La mayoria de los centros sanitarios en nuestros paises de estudio fueron equipados de forma insuficiente para proporcionar atencion sanitaria basica. Si los paises van a reforzar la capacidad del sistema sanitario hasta conseguir la cobertura universal, se necesita poner mas atencion a las desigualdades dentro del pais., Introduction In adopting the sustainable development goals (SDGs) in September 2015, global governments and multilateral organizations endorsed universal health coverage as both a critical element of sustainable development and a [...]

Objective To analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. Methods We pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 20062014). Based on World Health Organization protocols, we created indices of process quality for antenatal care (first visits) and for sick-child visits. We assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service. Findings Data were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% (interquartile range, IQR: 50.0 to 75.0) of eight recommended antenatal care actions and 54.5% (IQR: 33.3 to 66.7) of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better--managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better--and less--equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. Conclusion The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care. Objectif Analyser les facteurs qui affectent les variations de qualite observees concernant les soins prenatals et aux enfants malades dans des etablissements de soins primaires de sept pays africains. Methodes Nous avons rassemble des donnees representatives a l'echelle nationale provenant d'enquetes evaluant la qualite des services fournis par des etablissements de sante situes au Kenya, au Malawi, en Namibie, en Ouganda, en Republique-Unie de Tanzanie, au Rwanda et au Senegal (annees couvertes par les enquetes: 2006-2014). Nous avons cree des indices de qualite du processus pour les soins prenatals (premieres visites) et les visites aux enfants malades en nous appuyant sur les protocoles de l'Organisation mondiale de la Sante. A l'aide de differents modeles de regression multiniveaux de qualite pour chague service, nous avons evalue des facteurs lies aux pays, aux etablissements, aux prestataires et aux patients susceptibles d'expliquer les variations qualitatives des soins. Resultats Nous avons dispose de donnees tirees de 2594 observations de consultations cliniques pour des soins prenatals et de 11 402 observations de consultations cliniques pour des enfants malades. Dans l'ensemble, les prestataires de soins de sante ont realise en moyenne 62,2% (intervalle interquartile, IQR: de 50,0 a 75,0) des huit actions de soins prenatals recommandees et 54,5% (IQR: de 33,3 a 66,7) des neuf actions de soins aux enfants malades lors des visites observees. Les soins prenatals etaient de meilleure qualite dans les etablissements mieux dotes en personnel et mieux equipes et ceux fournis par les medecins et les cliniciens se sont reveles de moins bonne qualite que ceux des infirmiers. Les prestataires experimentes ainsi que ceux qui exercaient dans des etablissements mieux geres ont fourni des soins de meilleure gualite aux enfants malades, aucune difference n'ayant ete observee entre les medecins ou les infirmiers ou entre les centres de consultation mieux eguipes et ceux moins bien equipes. Les etablissements prives ont obtenu de meilleurs resultats que les etablissements publics. Les differences entre les pays ont davantage permis d'expliguer les variations de gualite gue tous les autres facteurs combines. Conclusion Deux services de soins primaires essentiels pour les femmes et les enfants se sont reveles de gualite mediocre, celle-ci variant selon les pays et au sein des pays. Une analyse des raisons des variations qualitatives permettrait de definir des strategies afin d'ameliorer les soins. Objetivo Analizar los factores que afectan a las variaciones de la calidad observada en la atencion prenatal y a ninos enfermos en centros de atencion primaria de siete paises africanos. Metodos Se recopilaron datos representativos a nivel nacional de encuestas de evaluacion sobre prestacion de servicios de centros sanitarios de Kenya, Malawi, Namibia, la Republica Unida de Tanzania, Rwanda, Senegal y Uganda (rango anual de encuestas: 2006-2014). En base a los protocolos de la Organizacion Mundial de la Salud, se crearon indices de calidad de procesos para la atencion prenatal (primeras consultas) y para las consultas a ninos enfermos. Se evaluaron los factores nacionales, de centros, de proveedores y de pacientes gue pudieran explicar las variaciones en la calidad de la atencion mediante el uso de distintos modelos de regresion en multiples niveles de calidad para cada servicio. Resultados Se disponia de los resultados para 2 594 y 11 402 observaciones de consultas medicas de atencion prenatal y atencion a ninos enfermos, respectivamente. En general, los profesionales sanitarios realizaron una media de 62,2% (rango intercuartilico, ICR: 50,0 a 75,0) de ocho acciones de atencion prenatal recomendadas y de 54,5% (ICR: 33,3 a 66,7) de nueve acciones de atencion a ninos enfermos en las visitas observadas. La calidad de la atencion prenatal fue mejor en los centros con mejor personal y mejores eguipos e inferior para los medicos y asistentes clinicos que para los enfermeros. Los proveedores con experiencia y aquellos en centros con una mejor gestion ofrecieron una atencion a ninos enfermos de mejor calidad, sin diferencias entre medicos y enfermeros o entre centros mejor o peor equipados. Los centros privados superaron la calidad de los publicos. Las diferencias entre paises tuvieron un papel mas influyente a la hora de explicar la varianza en la calidad gue el resto de factores juntos. Conclusion La calidad de dos servicios de atencion primaria basicos para mujeres y ninos era escasa y diversa entre paises y dentro de ellos. El analisis de las razones de las variaciones en la calidad podria identificar estrategias para mejorar la atencion., Introduction Although substantial progress has been made in reducing child and maternal deaths in the past 15 years, many women and children in low- and middle-income countries continue to die [...]

Author(s): Gagan Thapa 1, Manoj Jhalani 2, Sebastián García-Saisó 3, Address Malata 4, Sanam Roder-DeWan 5,6,7, Hannah H. Leslie 7,* Long a concern in high-income countries, health system quality emerged [...]

Objective To determine the optimal strategy for cervical cancer screening in women with human immunodeficiency virus (HIV) infection by comparing two strategies: visual inspection of the cervix with acetic acid (VIA) and VIA followed immediately by visual inspection with Lugol's iodine (VIA/VILI) in women with a positive VIA result. Methods Data from a cervical cancer screening programme embedded in two HIV clinic sites in western Kenya were evaluated. Women at a central site underwent VIA, while women at a peripheral site underwent VIA/VILI. All women positive for cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) on VIA and/or VILI had a confirmatory colposcopy, with a biopsy if necessary. Overall test positivity, positive predictive value (PPV) and the CIN 2+ detection rate were calculated for the two screening methods, with biopsy being the gold standard. Findings Between October 2007 and October 2010,2338 women were screened with VIA and 1124 with VIA/VILI. In the VIA group, 26.4% of the women tested positive for CIN 2+; in the VIA/VILI group, 21.7% tested positive (P< 0.01). Histologically confirmed CIN 2+ was detected in 8.9% and 7.8% (P=0.27) of women in the VIA and VIA/VILI groups, respectively. The PPV of VIA for biopsy- confirmed CIN 2+ in a single round of screening was 35.2%, compared with 38.2% for VIA/VILI (P=0.41). Conclusion The absence of any differences between VIA and VIA/VILI in detection rates or PPV for CIN 2+ suggests that VIA, an easy testing procedure, can be used alone as a cervical cancer screening strategy in low-income settings. Objectif Determiner la strategie optimale pour depister le cancer du col de l'uterus chez les femmes infectees par le virus de l'immunodeficience humaine (VIH) en comparant deux strategies: l'inspection visuelle du col de l'uterus en utilisant de l'acide acetique (IVA) et l'IVA sulvle immediatement par une inspection visuelle en utilisant du solute de Lugol (IVA/IVL) chez les femmes ayantobtenu un resultat positif pour l'IVA. Methodes Les donnees provenant d'un programme de depistage du cancer du col de l'uterus mis en oeuvre dans deux sites cliniques pour le VIH dans l'ouest du Kenya ont ete evaluees. Les femmes qul consultaient dans un site central ont ete examinees par IVA alors que les femmes qui consultaient dans un site peripherique ont ete examinees par IVA/IVL. Toutes les femmes presentant un resultat positif pour une neoplasie intraepltheliale du col de l'uterus de grade 2 ou superleur (CIN 2+) apres examen par IVA et/ou IVL ont ensuite eu une colposcople de confirmation, avec une biopsie si necessaire. La positivite globale du test, la valeur predictive positive (VPP) et le taux de detection des lesions CIN 2+ ont ete calcules pour les deux methodes de depistage, avec la biopsie comme reference absolue. Resultats Entre octobre 2007 et octobre 2010, 2338 femmes ont ete examinees par IVA et 1124 par IVA/IVL. Dans le groupe IVA, 26,4% des femmes ont obtenu un resultat positif pour des lesions CIN 2+; dans le groupe IVA/IVL, 21,7% des femmes ont obtenu un resultat positif (P< 0,01). Des lesions CIN 2+ confirmees hlstologiquement ont ete detectees chez 8,9% et 7,8% (P=0,27) des femmes dans les groupes IVA et IVA/IVL, respectlvement. La VPP de l'IVA pour les lesions CIN 2+ confirmees par biopsie dans une seule serie de depistage etalt de 35,2%, contre 38,2% pour l'IVA/IVL (P=0,41). Conclusion L'absence de difference entre UVA et l'IVA/IVL pour les taux de detection ou la VPP des lesions CIN 2+ suggere que l'IVA est une procedure de test simple, qul peut etre utilisee seule comme strategie de depistage du cancer du col de l'uterus dans les pays a falble revenu. Objetivo Determinar la mejor estrategia para detectar el cancer de cuello uterino en las mujeres con el virus de inmunodeficiencla humana (VIH) mediante la comparacion de dos estrategias: la inspeccion visual del cuello uterino con acido acetico (IVAA) y la IVAA seguida inmediatamente de la Inspeccion visual con yodo de Lugol (IVAA/IVYL) en mujeres con un resultado positivo en la IVAA. Metodos Se evaluaron los datos de un programa de deteccion de cancer de cuello uterino integrado en dos centros clinicos de VIH en el oeste de Kenya. Las mujeres de una zona central se sometieron a la IVAA, mientras que las mujeres de una zona periferica se sometieron a la IVAA/IVYL. Se realizo una colposcopia de confirmacion, ademas de una biopsla cuando era necesario, a todas las mujeres con un diagnostico positivo de neoplasia intraepitelial cervical de grado 2 o peor (CIN 2+) en la IVAA y/o IVYL. Se calculo la positividad de la prueba general, el valor predlctivo positivo (VPP) y la tasa de deteccion de CIN 2+ de ambos metodos de deteccion, con la biopsia como la regla de oro. Resultados Entre octubre de 2007 y octubre de 2010, se examino a 2338 mujeres con la IVAA y a 1124 con la IVAA/IVYL. En el grupo IVAA, el 26,4 % de las mujeres dio positivo en CIN 2+, mientras que en el grupo IVAA/IVYL, el 21,7 % dio positivo (P < 0,01). Se detecto CIN 2+ con confirmacion histologica en el 8,9 % y el 7,8 % (P = 0,27) de las mujeres de los grupos IVAA y IVAA/IVYL, respectivamente. El VPP de la IVAA para detectar CIN 2+ con confirmacion por biopsia en una ronda unica de deteccion fue del 35,2 %, comparado con el 38,2 % de IVAA/ IVYL (P= 0,41). Conclusion La ausencia de diferencias entre la IVAA y la IVAA/IVYL en las tasas de deteccion o el VPP para detectar CIN 2+ Indica que la IVAA, un procedimiento de prueba sencillo, puede utilizarse por separado como estrategia de deteccion de cancer cervical en comunidades de bajos ingresos., Introduction Cervical cancer is the second most common cancer among women in low- and middle-income countries (LMICs), where resources for cancer prevention programmes are often scarce. (1) Rates of cervical [...]

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., Author(s): Hannah H. Leslie *, Zeye Sun, Margaret E. Kruk Introduction The first decade of the 2000s saw a dramatic increase in global health activity, with double-digit increases in international [...]

Background Patient-reported measures attempt to quantify the value health services provide to users. Satisfaction is a common summative measure, but often has limited utility in identifying poor quality care. We compared satisfaction and the net promoter score (NPS), which was developed to help businesses quantify consumer sentiment, in a nationally representative survey in Peru. We aimed to compare NPS and satisfaction as individual ratings of care, assess the relationship of patient-reported experience ratings to these outcome measures and consider the utility of these measures as indicators of facility performance based on reliability within facilities and capacity to discriminate between facilities. Methods We analysed the 2016 National Survey on User Satisfaction of Health Services, a cross- sectional outpatient exit survey. We assessed ratings by patient characteristics and compared the distributions of satisfaction and NPS categories. We tested the association of patient-reported experience measures with each outcome using multilevel ordinal logistic regression. We used intraclass correlation (ICC) from these models to predict minimum sample for reliable assessment and compared patient- reported experience measures in facilities with average satisfaction but below or above average NPS. Results 13 434 individuals rated services at 184 facilities. Satisfaction (74% satisfied) and NPS (17% reported at least 9 out of 10) were largely concordant within individuals but weakly correlated (0.37). Ratings varied by individual factors such as age and visit purpose. Most domains of patient-reported experience were associated with both outcomes. Adjusted ICC was higher for NPS (0.26 vs 0.11), requiring a minimum of 7 (vs 20) respondents for adequate reliability. Within the 70% of facilities classified as average based on satisfaction, NPS- based classification revealed systematic differences in patient- reported experience measures. Conclusion While satisfaction and NPS were broadly similar at an individual level, this evidence suggests NPS may be useful for benchmarking facility performance as part of national efforts in Peru and throughout Latin America to identify deficits in health service quality. [ABSTRACT FROM AUTHOR]

Meaningful gains in health outcomes require successful implementation of evidence-based interventions. Organizations such as health facilities must be ready to implement efficacious interventions, but tools to measure organizational readiness have rarely been validated outside of high-income settings. We conducted a pilot study of the organizational readiness to implement change (ORIC) measure in public primary care facilities serving Bushbuckridge Municipality in South Africa in early 2019. We administered the 10-item ORIC to 54 nurses and lay counsellors in 9 facilities to gauge readiness to implement the national Central Chronic Medicine Dispensing and Distribution (CCMDD) programme intended to declutter busy health facilities. We used exploratory factor analysis (EFA) to identify factor structure. We used Cronbach alpha and intraclass correlation (ICC) to assess reliability at the individual and facility levels. To assess validity, we drew on existing data from routine clinic monitoring and a 2018 quality assessment to test the correlation of ORIC with facility resources, value of CCMDD programme, and better programme uptake and service quality. Six items from the ORIC loaded onto a single factor with Cronbach’s alpha of 0.82 and ICC of 0.23. While facility ORIC score was not correlated with implementation of CCMDD, higher scores were correlated with facility resources, perceived value of the CCMDD program, patient satisfaction with wait time, and greater linkage to care following positive HIV testing. The study is limited by measuring ORIC after programme implementation. The findings support the relevance of ORIC, but identify a need for greater adaptation and validation of the measure. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Recovery of health services disrupted by the COVID-19 pandemic represents a significant challenge in low- and middle-income countries. In April 2021, the Mexican Institute of Social Security (IMSS), which provides health care to 68.5 million people, launched the National Strategy for Health Services Recovery (Recovery policy). The study objective was to evaluate whether the Recovery policy addressed COVID-related declines in maternal, child health, and non-communicable diseases (NCDs) services. Methods We analysed the data of 35 IMSS delegations from January 2019 to November 2021 on contraceptive visits, antenatal care consultations, deliveries, caesarean sections, sick children's consultations, child vaccination, breast and cervical cancer screening, diabetes and hypertension consultations, and control. We focused on the period before (April 2020 - March 2021) and during (April 2021 - November 2021) the Recovery policy and used an interrupted time series design and Poisson Generalized Estimating Equation models to estimate the association of this policy with service use and outcomes and change in their trends. Results Despite the third wave of the pandemic in 2021, service utilization increased in the Recovery period, reaching (at minimum) 49% of pre-pandemic levels for sick children's consultations and (at maximum) 106% of pre-pandemic levels for breast cancer screenings. Evidence for the Recovery policy role was mixed: the policy was associated with increased facility deliveries (IRR = 1.15, 95%CI = 1.11-1.19) with a growing trend over time (IRR = 1.04, 95%CI = 1.03-1.05); antenatal care and child health services saw strong level effects but decrease over time. Additionally, the Recovery policy was associated with diabetes and hypertension control. Services recovery varied across delegations. Conclusions Health service utilization and NCDs control demonstrated important gains in 2021, but evidence suggests the policy had inconsistent effects across services and decreasing impact over time. Further efforts to strengthen essential health services and ensure consistent recovery across delegations are warranted. [ABSTRACT FROM AUTHOR]

Background Ending preventable newborn deaths is a global health priority, but efforts to improve coverage of maternal and newborn care have not yielded expected gains in infant survival in many settings. One possible explanation is poor quality of clinical care. We assess facility quality and estimate the association of facility quality with neonatal mortality in Malawi. Methods and Findings Data on facility infrastructure as well as processes of routine and basic emergency obstetric care for all facilities in the country were obtained from 2013 Malawi Service Provision Assessment. Birth location and mortality for children born in the preceding two years were obtained from the 2013-2014 Millennium Development Goals Endline Survey. Facilities were classified as higher quality if they ranked in the top 25% of delivery facilities based on an index of 25 predefined quality indicators. To address risk selection (sicker mothers choosing or being referred to higher-quality facilities), we employed instrumental variable (IV) analysis to estimate the association of facility quality of care with neonatal mortality. We used the difference between distance to the nearest facility and distance to a higher-quality delivery facility as the instrument. Four hundred sixty-seven of the 540 delivery facilities in Malawi, including 134 rated as higher quality, were linked to births in the population survey. The difference between higher- and lower-quality facilities was most pronounced in indicators of basic emergency obstetric care procedures. Higher-quality facilities were located a median distance of 3.3 km further from women than the nearest delivery facility and were more likely to be in urban areas. Among the 6,686 neonates analyzed, the overall neonatal mortality rate was 17 per 1,000 live births. Delivery in a higher-quality facility (top 25%) was associated with a 2.3 percentage point lower newborn mortality (95% confidence interval [CI] -0.046, 0.000, p-value 0.047). These results imply a newborn mortality rate of 28 per 1,000 births at low-quality facilities and of 5 per 1,000 births at the top 25% of facilities, accounting for maternal and newborn characteristics. This estimate applies to newborns whose mothers would switch from a lower-quality to a higher-quality facility if one were more accessible. Although we did not find an indication of unmeasured associations between the instrument and outcome, this remains a potential limitation of IV analysis. Conclusions Poor quality of delivery facilities is associated with higher risk of newborn mortality in Malawi. A shift in focus from increasing utilization of delivery facilities to improving their quality is needed if global targets for further reductions in newborn mortality are to be achieved., Author(s): Hannah H. Leslie 1,*, Günther Fink 1, Humphreys Nsona 2, Margaret E. Kruk 1 Introduction Eliminating preventable infant mortality is a global health priority, reaffirmed in Sustainable Development Goal [...]

Provision of high-quality HIV care is challenging, especially in rural primary care clinics in high HIV burden settings. We aimed to better understand the main challenges to quality HIV care provision and retention in antiretroviral treatment (ART) programs in rural South Africa from the health care providers' perspective. We conducted semi-structured qualitative interviews with 23 providers from nine rural clinics. Using thematic and framework analysis, we found that providers and patients face a set of complex and intertwined barriers at the structural, programmatic, and individual levels. More specifically, analyses revealed that their challenges are primarily structural (i.e., health system- and microeconomic context-specific) and programmatic (i.e., clinic- and provider-specific) in nature. We highlight the linkages that providers draw between the challenges they face, the motivation to do their job, the quality of the care they provide, and patients' dissatisfaction with the care they receive, all potentially resulting in poor retention in care. [ABSTRACT FROM AUTHOR]

Background: Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries.Methods and Findings: We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied.Conclusions: In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care. [ABSTRACT FROM AUTHOR]

This analysis describes specific gaps in the quality of health care in Central Africa and assesses the association between quality of clinical care and mortality at age 2-59 months. Regionally representative facility and household surveys for the Democratic Republic of the Congo, Cameroon and Central African Republic were collected between 2012 and 2016. These data are novel in linking facilities with households in their catchment area. Compliance with diagnostic and danger sign protocols during sick-child visits was observed by trained assessors. We computed facility- and district-level compliance indicators for patients aged 2-59 months and used multivariate multi-level logistic regression models to estimate the association between clinical assessment quality and mortality at age 2-59 months in the catchment areas of the observed facilities. A total of 13 618 live births were analysed and 1818 sick-child visits were directly observed and used to rate 643 facilities. Eight percent of observed visits complied with 80% of basic diagnostic protocols, and 13% of visits fully adhered to select general danger sign protocols. A 10% greater compliance with diagnostic protocols was associated with a 14.1% (adjusted odds ratio (aOR) 95% CI: 0.025-0.244) reduction in the odds of mortality at age 2-59 months; a 10% greater compliance with select general danger sign protocols was associated with a 15.3% (aOR 95% CI: 0.058-0.237) reduction in the same odds. The results of this article suggest that compliance with recommended clinical protocols remains poor in many settings and improvements in mortality at age 2-59 months could be possible if compliance were improved. [ABSTRACT FROM AUTHOR]

Background: Reductions in neonatal mortality remain stagnant, despite gains in health care access and utilization. Nutrition interventions during antenatal care (ANC) and in the immediate postpartum period are associated with improved neonatal outcomes. Adjusting coverage estimates for the quality of care provided yields greater insight into health system performance and potential population health benefits of accessing care. In this cross-sectional study, we adjust maternity care coverage measures for quality of nutrition interventions to determine the impact on infant birth weight and breastfeeding.Methods: We used household data from the Malawi 2013-2014 Multiple Indicator Cluster Survey to assess use of maternal health services and direct observations of ANC and delivery from the 2013 Service Provision Assessment to measure nutrition interventions provided. We adjusted coverage measures combining self-reported utilization of care with the likelihood of receipt of nutrition interventions. Using adjusted log-linear regression, we estimated the associations of these nutrition quality-adjusted metrics with infant birthweight and immediate breastfeeding.Results: Health facility data provided over 2500 directly observed clinical encounters and household data provided 7385 individual reports of health care utilization and outcomes. Utilization of ANC and facility-delivery was high. Women received nutrition-related interventions considerably less often than they sought care: over the course of ANC women received a median of 1.6 interventions on iron, 1 instance of nutrition counseling, and 0.06 instances of breastfeeding counseling. Nutrition quality-adjusted ANC coverage was associated with a reduced risk of low birthweight (adjusted relative risk [ARR] 0.87, 95% confidence interval (CI) = 0.79, 0.96) and increased likelihood of immediate breastfeeding (ARR = 1.04, 95% CI = 1.02, 1.07); nutrition quality-adjusted post-delivery care was also associated with greater uptake of immediate breastfeeding (ARR = 1.08, 95% CI = 1.02, 1.14). Based on these models, delivering nutrition interventions consistently within the existing level of coverage would decrease population prevalence of low birthweight from 13.7% to 10.8% and increase population prevalence of immediate breastfeeding from 75.9% to 86.0%.Conclusions: Linking household survey data to health service provision assessments demonstrates that despite high utilization of maternal health services in Malawi, low provision of nutrition interventions is undermining infant health. Substantial gains in newborn health are possible in Malawi if quality of existing services is strengthened. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to investigate factors associated with patient experience with primary care in a large public health system in Mexico and determine the amount of variability in experience attributable to facility-level and state-level factors. Methods: We analysed cross-sectional 2016 national satisfaction survey data from the Mexican Social Security Institute (IMSS). Patient-level data were merged with facility-level data and information on poverty by state. We assessed general contextual effects and examined the relationship of patient, facility and state factors with four patient experience measures using random effects logistic regression. Results: 25 745 patients’ responses from 319 facilities were analysed. The majority experienced good communication (78%), the opportunity to share health concerns (91%) and resolution of doubts (85%). 29% of visits were rated as excellent. Differences between facilities and states accounted for up to 12% and 6% of the variation in patient experience, respectively. Inclusion of facility-level contextual effects improved model predictions by 8%–12%; models with facility random effects and individual covariates correctly predicted 64%–71% of individual outcomes. In adjusted models, larger patient population was correlated with worse reported communication, less opportunity to share concerns and less resolution of doubts. Men reported more positive communication; older individuals reported more positive communication and experiences overall, but less opportunity to share concerns; and more educated individuals were less likely to report positive communication but more likely to report resolution of doubts and overall positive experiences. Preventive care visits were rated higher than curative visits for resolution of doubts, but lower for opportunity to share concerns, and specific conditions were associated with better or worse reported experiences in some cases. Conclusion: Quality improvement efforts at IMSS facilities might bolster individual experiences with primary care, given that up to 12% of the variation in experience was attributable to facility-level differences. The relationship between individual characteristics and experience ratings reinforces the importance of patients’ expectations of care and the potential for differential treatment by providers to impact experience. [ABSTRACT FROM AUTHOR]

Objective Increasing the availability of basic healthcare services in low-and middle-income countries is not sufficient to meet the Sustainable Development Goal target for child survival in high-mortality settings, where healthcare utilisation is often inconsistent and quality of care can be poor. We assessed whether poor quality of sick child healthcare in Malawi is associated with low utilisation of sick child healthcare. Design We measured two elements of quality of sick child healthcare: facility structural readiness and process of care using data from the 2013 Malawi Service Provision Assessment. Overall quality was defined as the average of these metrics. We extracted demographic data from the 2013-2014 Malawi Multiple Indicator Cluster Survey and linked households to nearby facilities using geocodes. We used logistic regression to examine the association of facility quality with utilisation of formal health services for children under 5 years of age suffering diarrhoea, fever or cough/acute respiratory illness, controlling for demographic and socioeconomic characteristics. We conducted sensitivity analyses (SAs), modifying the travel distance and population--facility matching criteria. Setting and population 568 facilities were linked with 9701 children with recent illness symptoms in Malawi, of whom 69% had been brought to a health facility. Results Overall, facilities showed gaps in structural quality (62% readiness) and major deficiencies in process quality (33%), for an overall quality score of 48%. Better facility quality was associated with higher odds of utilisation of sick child healthcare services (adjusted ORs (AOR): 1.66, 95% CI: 1.04 to 2.63), as was structural quality alone (AOR: 1.33, 95% CI: 0.95 to 1.87). SAs supported the main finding. Conclusion Although Malawi's health facilities for curative child care are widely available, quality and utilisation of sick child healthcare services are in short supply. Improving facility quality may provide a way to encourage higher utilisation of healthcare, thereby decreasing preventable childhood morbidity and mortality. [ABSTRACT FROM AUTHOR]