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Objective To identify contextual factors associated with quality improvements in primary health-care facilities in the United Republic of Tanzania between two star rating assessments, focusing on local district administration and proximity to other facilities. Methods Facilities underwent star rating assessments in 2015 and between 2017 and 2018; quality was rated from zero to five stars. The consolidated framework for implementation research, adapted to a low-income context, was used to identify variables associated with star rating improvements between assessments. Facility data were obtained from several secondary sources. The proportion of the variance in facility improvement observed at facility and district levels and the influence of nearby facilities and district administration were estimated using multilevel regression models and a hierarchical spatial autoregressive model, respectively. Findings Star ratings improved at 4028 of 5595 (72%) primary care facilities. Factors associated with improvement included: (i) star rating in 2015; (ii) facility type (e.g. hospital) and ownership (e.g. public); (iii) participation in, or eligibility for, a results-based financing programme; (iv) local population density; and (v) distance from a major road. Overall, 20% of the variance in facility improvement was associated with district administration. Geographical clustering indicated that improvement at a facility was also associated with improvements at nearby facilities. Conclusion Although the majority of facilities improved their star rating, there were substantial variations between facilities. Both district administration and proximity to high-performing facilities influenced improvements. Quality improvement interventions should take advantage of factors operating above the facility level, such as peer learning and peer pressure. Objectif Identifier les facteurs contextueis lies aux ameliorations de qualite dans les etablissements de soins de sante primaires en Republique-Unie de Tanzanie, entre deux scores, en se concentrant sur l'administration locale et la proximite vis-a-vis d'autres etablissements. Methodes Les etablissements se sont vus attribuer un score de zero a cinq etoiles en 2015 ainsi qu'un autre entre 2017 et 2018, afin d'evaluer leur qualite. C'est le cadre consolide pour la recherche sur la mise en reuvre, adapte a ce pays a faible revenu, qui a ete utilise pour degager des variables associees aux ameliorations de score entre chaque periode d'evaluation. Les donnees sur les etablissements ont ete collectees aupres de plusieurs sources secondaires. La proportion de la variance d'amelioration observee a l'echelle de l'etablissement et du district ainsi que (influence des etablissements a proximite et de l'administration locale ont ete mesurees a l'aide de modeles de regression multiniveaux pour l'un, et d'un modele autoregressif spatial hierarchique de l'autre. Resultats Le score a augmente dans 4028 des 5595 (72%) etablissements de soins de sante primaires. Parmi les facteurs lies a cette amelioration, citons: (i) le nombre d'etoiles attribuees en 2015; (ii) le type d'etablissement (un hopital par exemple) et son proprietaire (l'Etat par exemple); (iii) la participation a ou l'eligibilite a un programme de financement fonde sur les resultats; (iv) la densite de population locale; et enfin, (v) la distance par rapport a un axe routier majeur. Au total, 20% de la variance d'amelioration de l'etablissement etait inherente a l'administration du district. Et d'apres le regroupement geographique, l'amelioration d'un etablissement etait egalement tributaire de celle des etablissements a proximite. Conclusion Bien que la majorite des etablissements aient ameliore leur score, des ecarts considerables subsistent entre eux. Tant l'administration de district que la proximite d'etablissements hautement performants ont eu un impact sur leur progression. Les interventions visant a renforcer la qualite devraient tirer profit des facteurs situes hors des murs de l'etablissement, tels que l'enseignement mutuel et la pression exercee par les pairs. Objetivo Identificar los factores contextuales de las mejoras de la calidad en los establecimientos de atencion primaria de salud de la Republica Unida de Tanzania entre las dos evaluaciones de clasificacion por estrellas, en las que se presta especial atencion a la administracion local de los distritos y a la proximidad de otros establecimientos. Metodos Se realizaron evaluaciones de clasificacion por estrellas a los establecimientos en 2015 y entre 2017 y 2018; la calidad se clasifico de cero a cinco estrellas. El marco consolidado de la investigacion sobre la aplicacion, que se adapto a un contexto de bajos ingresos, se utilizo para identificar las variables relacionadas con las mejoras en la clasificacion por estrellas entre las evaluaciones. Los datos de los establecimientos se obtuvieron de varias fuentes secundarias. El porcentaje de la varianza en la mejora de los establecimientos que se observo a nivel de establecimiento y de distrito y la influencia de los establecimientos cercanos y de la administracion del distrito se estimaron por medio de los modelos de regresion de multinivel y de un modelo autorregresivo espacial jerarquico, respectivamente. Resultados La clasificacion por estrellas mejoro en 4028 de 5595 (72 %) establecimientos de atencion primaria. Los factores de la mejora incluyeron: i) la clasificacion por estrellas de 2015; ii) el tipo de establecimiento (por ejemplo, hospital) y la propiedad (por ejemplo, publica); iii) la participacion en un programa de financiamiento por resultados o la posibilidad de obtenerlo; iv) la densidad de poblacion local; y v) la distancia a una carretera principal. En general, el 20 % de la variacion en la mejora de los establecimientos se asocio a la administracion del distrito. La agrupacion geografica indico que la mejora de un establecimiento tambien estaba asociada con las mejoras de los establecimientos cercanos. Conclusion Aunque la mayoria de los establecimientos mejoraron su clasificacion por estrellas, se registraron variaciones significativas entre los establecimientos. Tanto la administracion del distrito como la proximidad de los establecimientos de gran rendimiento influyeron en las mejoras. Las intervenciones de la mejora de la calidad deben aprovechar los factores que funcionan por encima del nivel del establecimiento, como el aprendizaje entre iguales y la presion social. [phrase omitted], Introduction Following the Astana declaration in 2018, primary health care is again high on the global health agenda and many countries are renewing their commitments to strengthening primary care. (1) [...]

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 [...]

Background High satisfaction with healthcare is common in low- and middle-income countries (LMICs), despite widespread quality deficits. This may be due to low expectations because people lack knowledge about what constitutes good quality or are resigned about the quality of available services. Methods and findings We fielded an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal, and South Africa in 2017 (N = 17,996). It included vignettes describing poor-quality services-inadequate technical or interpersonal care-for 2 conditions. After applying population weights, most of our respondents lived in urban areas (59%), had finished primary school (55%), and were under the age of 50 (75%). Just over half were men (51%), and the vast majority reported that they were in good health (73%). Over half (53%) of our study population rated the quality of vignettes describing poor-quality services as good or better. We used multilevel logistic regression and found that good ratings were associated with less education (no formal schooling versus university education; adjusted odds ratio [AOR] 2.22, 95% CI 1.90-2.59, P < 0.001), better self-reported health (excellent versus poor health; AOR 5.19, 95% CI 4.33-6.21, P < 0.001), history of discrimination in healthcare (AOR 1.47, 95% CI 1.36-1.57, P < 0.001), and male gender (AOR 1.32, 95% CI 1.23-1.41, P < 0.001). The survey did not reach nonusers of the internet thus only representing the internet-using population. Conclusions Majorities of the internet-using public in 12 LMICs have low expectations of healthcare quality as evidenced by high ratings given to poor-quality care. Low expectations of health services likely dampen demand for quality, reduce pressure on systems to deliver quality care, and inflate satisfaction ratings. Policies and interventions to raise people's expectations of the quality of healthcare they receive should be considered in health system quality reforms., Author(s): Sanam Roder-DeWan 1,2,3,*, Anna D. Gage 1, Lisa R. Hirschhorn 4, Nana A. Y. Twum-Danso 5,6, Jerker Liljestrand 7, Kwanele Asante-Shongwe 8, Viviana Rodríguez 9, Talhiya Yahya 10, Margaret [...]

Background A recent systematic review evaluated the effectiveness of strategies to improve healthcare provider (HCP) performance in low-income and middle-income countries. The review identified strategies with varying effects, including in-service training, supervision and group problem-solving. However, whether their effectiveness changed over time remained unclear. In particular, understanding whether effects decay over time is crucial to improve sustainability. Methods We conducted a secondary analysis of data from the aforementioned review to explore associations between time and effectiveness. We calculated effect sizes (defined as percentage-point (%-point) changes) for HCP practice outcomes (eg, percentage of patients correctly treated) at each follow-up time point after the strategy was implemented. We estimated the association between time and effectiveness using random-intercept linear regression models with time-specific effect sizes clustered within studies and adjusted for baseline performance. Results The primary analysis included 37 studies, and a sensitivity analysis included 77 additional studies. For training, every additional month of follow-up was associated with a 0.19 %-point decrease in effectiveness (95% CI: -0.36 to -0.03). For training combined with supervision, every additional month was associated with a 0.40 %-point decrease in effectiveness (95% CI: -0.68 to -0.12). Time trend results for supervision were inconclusive. For group problem-solving alone, time was positively associated with effectiveness, with a 0.50 %-point increase in effect per month (95% CI: 0.37 to 0.64). Group problem-solving combined with training was associated with large improvements, and its effect was not associated with time. Conclusions Time trends in the effectiveness of different strategies to improve HCP practices vary among strategies. Programmes relying solely on in-service training might need periodical refresher training or, better still, consider combining training with group problemsolving. Although more high-quality research is needed, these results, which are important for decision-makers as they choose which strategies to use, underscore the utility of studies with multiple post-implementation measurements so sustainability of the impact on HCP practices can be assessed. [ABSTRACT FROM AUTHOR]

We sought to understand the experiences of parents who participated in Group Well-Child Care (GWCC) and Trauma-Informed GWCC (TI-GWCC). Three focus groups and design sessions with parents from either standard GWCC or TI-GWCC (N = 17) were conducted and synthesized into common themes using thematic analysis. Focus group themes included: (1) GWCC can empower parents to recognize toxic stress; (2) Parents identify ways that they role model behaviors for their child(ren); (3) Activities that facilitate reflection on attachment and anger management encourage intentional parenting practices. Our qualitative findings suggest that TI-GWCC supports the prevention of childhood adversity by creating connections between parents, helping families understand and identify toxic stress, and teaching parenting practices that mitigate stressors. [ABSTRACT FROM AUTHOR]

The question of how to optimally design health systems in low- and middle-income countries (LMICs) for high quality care and survival requires context-specific evidence on which level of the health system is best positioned to deliver services. Given documented poor quality of care for surgical conditions in LMICs, evidence to support intentional health system design is urgently needed. Iverson and colleagues address this very important question. This commentary explores their findings with particular attention to how they apply to maternity care. Though surgical maternity care is a common healthcare need, maternal complications are often unpredictable and require immediate surgical attention in order to avert serious morbidity or mortality. A discussion of decentralization for maternity services must grapple with this tension and differentiate between facilities that can provide emergency surgical care and those that can not. [ABSTRACT FROM AUTHOR]

Objectives: Describe experiences of countries with networks of care's (NOCs') financial arrangements, identifying elements, strategies and patterns., Design: Descriptive using a modified cross-case analysis, focusing on each network's financing functions (collecting resources, pooling and purchasing)., Setting: Health systems in six countries: Argentina, Australia, Canada, Singapore, the United Kingdom and the USA., Participants: Large-scale NOCs., Results: Countries differ in their strategies to implement and finance NOCs. Two broad models were identified in the six cases: top-down (funding centrally designed networks) and bottom-up (financing individual projects) networks. Despite their differences, NOCs share the goal of improving health outcomes, mainly through the coordination of providers in the system; these results are achieved by devoting extra resources to the system, including incentives for network formation and sustainability, providing extra services and setting incentive systems for improving the providers' performance., Conclusions: Results highlight the need to better understand the financial implications and alternatives for designing and implementing NOCs, particularly as a strategy to promote better health in low- and middle-income settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)