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Just after dawn, Vivej arrives at the hospital with her newborn under her arm to see you. She is 21 years old, two days postpartum, and exhausted after 36 hours of protracted labor. She is worried because she cannot get her firstborn, Esmile, to breastfeed. You learn that she delivered at a birthing clinic near her home and tells you that, even after her water broke, it took more than a day before the birth attendant could deliver her son. Your examination reveals a dire clinical picture: Esmile is lethargic and hypotonic, he has a poor suck reflex, his temperature is 39.8°C, his pulse is 180, and his breathing is labored. You check his white blood count, confirming leukocytosis. A spinal tap shows pleocytosis. You start him on fluids and antibiotics for neonatal sepsis with likely meningitis and quickly turn your attention to Vivej. Her situation is easier to diagnose but no less urgent: she is febrile and tachycardic, her blood pressure is 85/50. You give her fluids and start her on antibiotics. Ultimately, despite your efforts, both mother and child die.What went wrong? This chapter looks narrowly at these situations—the critical points after access and availability (including affordability) are already accomplished, when patients are in health care facilities that are staffed and equipped with appropriate technology. These are the situations in which the inputs are brought together and it is up to the provider to improve the health of the patient. Simply put, this chapter looks at the decisions and actions of the provider when seeing a patient. It is at this critical moment when we expect the doctor or nurse, or whoever is caring for the patient, to provide the best possible care by skillfully combining the available resources and technologies with the best clinical evidence and professional judgment.Esmile and Vivej received poor-quality care at the time of delivery. Several clinical steps were not taken. The prolonged rupture of membranes was not diagnosed in a timely manner. Vivej needed either to have her labor induced or, failing that, to be referred for a cesarean section. Prophylactic antibiotics should have been administered. Just as important, the provider at the birthing center needed support and professional oversight, with guidelines, supervision, or default referral systems in place to provide a path to the best care possible. The multiple failures in this case led to puerperal and neonatal sepsis. At worst, these conditions have a fatality rate greater than one in four; at best, they lead to protracted care, recovery, and clinical expense that could have been avoided. It is possible, however, to imagine providers in a different setting, with the same physical resources, giving better care and avoiding this tragic scenario.In the next section, we answer the questions raised in this scenario and in countless clinics and hospitals around the world. How much variation is there in the quality of care? How do we measure clinical practice? How and where has quality been systematically improved and practice variation reduced? What elements of care variation can be addressed by policy and what are the costs? Most important, what can be done to elevate the care given by providers in developing country settings? Our focus, therefore, is on the steps that can be taken to optimize the quality of care for patients like Esmile in pediatrics, Vivej in obstetrics, and other patients receiving care for the clinical conditions considered throughout the nine volumes of the third edition of Disease Control Priorities (DCP3).

Health systems have several key objectives; the most fundamental is to improve the health of the population. In addition, they are concerned with the distribution of health in the population—for example, with health equity—and they strive to be responsive to the needs of the population and to deliver services efficiently (WHO 2007). Notably, they also seek to provide protection against the financial risks that individuals face when accessing health services. Ideally, this financial risk protection (FRP) is accomplished through mechanisms such as risk pooling and group payment that ensure prepayment of most, if not all, health care costs (Jamison and others 2013).An effective health system is one that meets these objectives by providing equitable access to affordable, high-quality health care—including treatment and curative services as well as health promotion, prevention, and rehabilitation services—to the entire population. Unfortunately, most countries lack health systems that meet this standard. Shortfalls in access, quality, efficiency, and equity have been documented extensively, both in low- and middle-income countries (LMICs) and in some high-income countries (HICs) (WHO 2010). In addition, in many countries, households routinely face catastrophic or impoverishing health expenditure when seeking acute or chronic disease care (Xu and others 2007). These financial risks can result in further health loss and reduced economic prosperity for households and populations (Kruk and others 2009; McIntyre and others 2006).The current universal health coverage (UHC) movement emerged in response to a growing awareness of the worldwide problems of low access to health services, low quality of care, and high levels of financial risk (Ji and Chen 2016). UHC is now a core tenet of United Nations (UN) Sustainable Development Goal (SDG) 3. UHC was preceded by the aspirational notion of a minimum standard of health for all, enshrined in the Universal Declaration of Human Rights (adopted by the UN General Assembly in 1948) and the declaration of Alma-Ata in 1978, and many HICs have provided universal coverage for decades. The World Health Assembly endorsed the modern concept of UHC as an aspiration for all countries in 2005. Subsequent World Health Reports by the World Health Organization (WHO) expanded on various technical aspects of UHC, and in 2015, UHC was adopted as a subgoal (target 3.8) of SDG 3 (UN 2016; WHO 2013b).Mechanisms and approaches, summarized elsewhere (WHO 2010; WHO 2013b), have been proposed or attempted as specific means of achieving UHC, but the objectives of UHC are the same in all settings, regardless of approach: improving access to health services (particularly for disadvantaged populations), improving the health of individuals covered, and providing FRP (Giedion, Alfonso, and Diaz 2013). There are three fundamental dimensions to UHC—proportion of population covered, proportion of expenditures prepaid, and proportion of health services included in UHC—that any given health care reform strategy seeks to achieve in some prioritized order (Busse, Schreyogg, and Gericke 2007). Recent reports, including the Lancet Commission on Investing in Health and the WHO Making Fair Choices consultation, have endorsed a “progressive universalist” approach to public finance of UHC (Jamison and others 2013; WHO 2014). Progressive universalism makes the case, on the basis of efficiency and equity, for an expansion pathway through the three UHC dimensions that prioritizes full population coverage and prepayment, albeit for a narrower scope of services than could be achieved at lower coverage levels or through cost-sharing arrangements. (It has been argued that full population coverage and full prepayment are necessary conditions to ensure that UHC leaves no one behind [WHO 2014].)If progressive universalism is the preferred approach to UHC, then a critical question for health planners is which health interventions should be included. HICs are able to provide a wide array of health services, but LMICs have the resources to deliver a smaller set of services, necessitating a more explicit and systematic approach to priority setting (Glassman and others 2016). In this spirit, the Making Fair Choices report recommended that UHC focus on interventions that are the most cost-effective, improve the health of the worst off, and provide FRP (WHO 2014). The extended cost-effectiveness analysis (ECEA) approach developed for this third edition of Disease Control Priorities (DCP3) assesses policies in these dimensions and can help identify efficient, fair pathways to UHC. Chapter 8 of this volume provides an overview of ECEA methods and results of ECEAs undertaken in conjunction with DCP3 (Verguet and Jamison 2018).The set of prioritized health services publicly financed through a UHC scheme has been termed a health benefits package (Glassman and others 2016). The limited experience of LMICs with benefits packages suggests that such packages can be part of a coherent and efficient approach to health system strengthening, but many countries lack the technical capacity to review a broad range of candidate interventions and summarize the evidence for their effectiveness or cost-effectiveness. In this regard, DCP3 provides guidance on priority health interventions for UHC in LMICs in the form of a model health benefits package that is based on DCP3’s 21 essential packages (see chapter 1 of this volume, Jamison and others 2018).This chapter proposes a concrete set of priorities for UHC that is grounded in economic reality and is intended to be appropriate to the health needs and constraints of LMICs, particularly low-income countries and lower-middle-income countries. It develops a model benefits package referred to as essential UHC (EUHC) and identifies a subset of interventions termed the highest-priority package (HPP). The chapter presents a case that all countries, including low-income countries, could strive to fully implement the HPP interventions by the end of the SDG period (2030), and many middle-income countries could strive to achieve full implementation of EUHC. The chapter also presents estimates of the EUHC and HPP costs and mortality consequences. It concludes with a discussion of measures that improve the uptake and quality of health services and with some remarks on the implications of EUHC and the HPP for health systems.The chapter does not, however, prescribe one correct approach to UHC, nor does it attempt to review the wide array of delivery mechanisms, policy instruments, and financial arrangements that support the transition to UHC; these have been covered in detail elsewhere (WHO 2010; World Bank 2016). Rather, this chapter stresses that the UHC priority-setting process is contextual, depending on political economy as well as local costs, budgets, and demographic and epidemiological factors—all of which influence the value for money of specific interventions.Because the development and refinement of a benefits package is an incremental and iterative process, many ministries of health probably will not use DCP3’s recommendations as a template for their packages but rather as an aid in reviewing existing services, identifying outliers, and considering services that are not currently provided. The DCP3 model benefits package can thus serve as a starting point for deliberation on a new health benefits package or refinement of an existing package. However, as construed here, it would not be a perfect package for a particular country. To translate the DCP3 findings into an actionable UHC agenda at the national or subnational level will require context-specific technical analyses and public consultation, ideally as part of a clearly articulated political agenda and an institutionalized priority-setting process that can govern public and donor resource allocation in the health sector.

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.

Non-communicable diseases (NCDs) are the greatest contributor to morbidity and mortality in low- and middle-income countries (LMICs). However, NCD care is limited in LMICs, particularly among the disadvantaged and rural. We explored the role of insurance in mitigating socioeconomic and urban-rural disparities in NCD treatment across 48 LMICs included in the 2002–2004 World Health Survey (WHS). We analyzed data about ever having received treatment for diagnosed high-burden NCDs (any diagnosis, angina, asthma, depression, arthritis, schizophrenia, or diabetes) or having sold or borrowed to pay for healthcare. We fit multivariable regression models of each outcome by the interaction between insurance coverage and household wealth (richest 20% vs. poorest 50%) and urban- icity, respectively. We found that insurance was associated with higher treatment likelihood for NCDs in LMICs, and helped mitigate socioeconomic and regional disparities in treatment likelihood. These influences were particularly strong among women. Insurance also predicted lower likelihood of borrowing or selling to pay for health services among the poorest women. Taken together, insurance coverage may serve as an important policy tool in promoting NCD treatment and in reducing inequities in NCD treatment by household wealth, urbanicity, and sex in LMICs.

In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite efforts to reduce barriers to utilization. Disrespect and abuse during childbirth has not been explored as a contributor to delivery satisfaction or as a deterrent to institutional delivery. We assessed the association between reported disrespectful treatment during childbirth and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. Interviews using a structured questionnaire were conducted in Tanga Region, Tanzania with women on discharge from delivery at two hospitals. Disrespect and abuse was measured by asking women about specific disrespectful events during childbirth. Multivariable logistic regression models were used to assess the association between disrespect/abuse and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. 1388 women participated in the survey (67 % response rate). Disrespect/abuse during childbirth was associated with lower satisfaction with delivery (OR 0.26, 95 % CI 0.19–0.36) and reduced likelihood of rating perceived quality of care as excellent/very good (OR 0.55, 95 % CI 0.35–0.85). Of women who planned to have more children (N = 766), those who experienced disrespect/abuse were half as likely to plan to deliver again at the same facility (OR 0.51, 95 % CI 0.32–0.82). Our study highlights disrespectful and abusive treatment during childbirth as an important factor in reducing women’s confidence in health facilities. Improving interpersonal care must be an integral part of quality improvement in maternal health.

Summary Background The way in which a government chooses to finance a health intervention can affect the uptake of health interventions and consequently the extent of health gains. In addition to health gains, some policies such as public finance can insure against catastrophic health expenditures. We aimed to evaluate the health and financial risk protection benefits of selected interventions that could be publicly financed by the government of Ethiopia. Methods We used extended cost-effectiveness analysis to assess the health gains (deaths averted) and financial risk protection afforded (cases of poverty averted) by a bundle of nine (among many other) interventions that the Government of Ethiopia aims to make universally available. These nine interventions were measles vaccination, rotavirus vaccination, pneumococcal conjugate vaccination, diarrhoea treatment, malaria treatment, pneumonia treatment, caesarean section surgery, hypertension treatment, and tuberculosis treatment. Findings Our analysis shows that, per dollar spent by the Ethiopian Government, the interventions that avert the most deaths are measles vaccination (367 deaths averted per $100 000 spent), pneumococcal conjugate vaccination (170 deaths averted per $100 000 spent), and caesarean section surgery (141 deaths averted per $100 000 spent). The interventions that avert the most cases of poverty are caesarean section surgery (98 cases averted per $100 000 spent), tuberculosis treatment (96 cases averted per $100 000 spent), and hypertension treatment (84 cases averted per $100 000 spent). Interpretation Our approach incorporates financial risk protection into the economic evaluation of health interventions and therefore provides information about the efficiency of attainment of both major objectives of a health system: improved health and financial risk protection. One intervention might rank higher on one or both metrics than another, which shows how intervention choice—the selection of a pathway to universal health coverage—might involve weighing up of sometimes competing objectives. This understanding can help policy makers to select interventions to target specific policy goals (ie, improved health or financial risk protection). It is especially relevant for the design and sequencing of universal health coverage to meet the needs of poor populations. Funding Bill & Melinda Gates Foundation.

We assessed whether quality of maternal and newborn health services is influenced by presence of HIV programs at Kenyan health facilities using data from a national facility survey. Facilities that provided services to prevent mother-to-child HIV transmission had better prenatal and postnatal care inputs, such as infrastructure and supplies, and those providing antiretroviral therapy had better quality of prenatal and postnatal care processes. HIV-related programs may have benefits for quality of care for related services in the health system.

Many patients in low-income countries express preferences for high-quality health care but often end up with low-quality providers. We conducted a randomized controlled trial with pregnant women in Nairobi, Kenya, to analyze whether cash transfers, enhanced with behavioral "nudges," can help women deliver in facilities that are consistent with their preferences and are of higher quality. We tested two interventions. The first was a labeled cash transfer (LCT), which explained that the cash was to help women deliver where they wanted. The second was a cash transfer that combined labeling and a commitment by the recipient to deliver in a prespecified desired facility as a condition of receiving the final payment (L-CCT). The L-CCT improved patient-perceived quality of interpersonal care but not perceived technical quality of care. It also increased women's likelihood of delivering in facilities that met standards for routine and emergency newborn care but not the likelihood of delivering in facilities that met standards for obstetric care. The LCT had fewer measured benefits. Women preferred facilities with high technical and interpersonal care quality, but these quality measures were often negatively correlated within facilities. Even with cash transfers, many women still used poor-quality facilities. A larger study is warranted to determine whether the L-CCT can improve maternal and newborn outcomes.

Summary Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.

BackgroundMeasles supplementary immunisation activities (SIAs) are an integral component of measles elimination in low-income and middle-income countries (LMICs). Despite their success in increasing vaccination coverage, there are concerns about their negative consequences on routine services. Few studies have conducted quantitative assessments of SIA impact on utilisation of health services.MethodsWe analysed the impact of SIAs on utilisation of selected maternal and child health services using Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 28 LMICs, where at least one SIA occurred over 2000–2014. Logistic regressions were conducted to investigate the association between SIAs and utilisation of the following services: facility delivery, postnatal care and outpatient sick child care (for fever, diarrhoea, cough).ResultsSIAs do not appear to significantly impact utilisation of maternal and child services. We find a reduction in care-seeking for treatment of child cough (OR 0.67; 95% CI 0.48 to 0.95); and a few significant effects at the country level, suggesting the need for further investigation of the idiosyncratic effects of SIAs in each country.ConclusionThe paper contributes to the debate on vertical versus horizontal programmes to ensure universal access to vaccination. Measles SIAs do not seem to affect care-seeking for critical conditions.

Objectives To determine the extent of provider communication, predictors of good communication and the association between provider communication and patient outcomes, such as patient satisfaction, in seven sub-Saharan African countries. Design Cross-sectional, multicountry study. Setting Data from recent Service Provision Assessment (SPA) surveys from seven countries in sub-Saharan Africa. SPA surveys include assessment of facility inputs and processes as well as interviews with caretakers of sick children. These data included 3898 facilities and 4627 providers. Participants 16 352 caregivers visiting the facility for their sick children. Primary and secondary outcome measures We developed an index of four recommended provider communication items for a sick child assessment based on WHO guidelines. We assessed potential predictors of provider communication and considered whether better provider communication was associated with intent to return to the facility for care. Results The average score of the composite indicator of provider communication was low, at 35% (SD 26.9). Fifty-four per cent of caregivers reported that they were told the child’s diagnosis, and only 10% reported that they were counselled on feeding for the child. Caregivers’ educational attainment and provider preservice education and training in integrated management of childhood illness were associated with better communication. Private facilities and facilities with better infrastructure received higher communication scores. Caretakers reporting better communication were significantly more likely to state intent to return to the facility (relative risk: 1.19, 95% CI 1.16 to 1.22). Conclusions There are major deficiencies in communication during sick child visits. These are associated with lower provider education as well as less well-equipped facilities. Poor communication, in turn, is linked to lower satisfaction and intention to return to facility among caregivers of sick children. Countries should test strategies for enhancing quality of communication in their efforts to improve health outcomes and patient experience.

Background Despite substantial financial contributions by the United States President’s Malaria Initiative (PMI) since 2006, no studies have carefully assessed how this program may have affected important population-level health outcomes. We utilized multiple publicly available data sources to evaluate the association between introduction of PMI and child mortality rates in sub-Saharan Africa (SSA). Methods and findings We used difference-in-differences analyses to compare trends in the primary outcome of under-5 mortality rates and secondary outcomes reflecting population coverage of malaria interventions in 19 PMI-recipient and 13 non-recipient countries between 1995 and 2014. The analyses controlled for presence and intensity of other large funding sources, individual and household characteristics, and country and year fixed effects. PMI program implementation was associated with a significant reduction in the annual risk of under-5 child mortality (adjusted risk ratio [RR] 0.84, 95% CI 0.74–0.96). Each dollar of per-capita PMI expenditures in a country, a measure of PMI intensity, was also associated with a reduction in child mortality (RR 0.86, 95% CI 0.78–0.93). We estimated that the under-5 mortality rate in PMI countries was reduced from 28.9 to 24.3 per 1,000 person-years. Population coverage of insecticide-treated nets increased by 8.34 percentage points (95% CI 0.86–15.83) and coverage of indoor residual spraying increased by 6.63 percentage points (95% CI 0.79–12.47) after PMI implementation. Per-capita PMI spending was also associated with a modest increase in artemisinin-based combination therapy coverage (3.56 percentage point increase, 95% CI −0.07–7.19), though this association was only marginally significant (p = 0.054). Our results were robust to several sensitivity analyses. Because our study design leaves open the possibility of unmeasured confounding, we cannot definitively interpret these results as causal. Conclusions PMI may have significantly contributed to reducing the burden of malaria in SSA and reducing the number of child deaths in the region. Introduction of PMI was associated with increased coverage of malaria prevention technologies, which are important mechanisms through which child mortality can be reduced. To our knowledge, this study is the first to assess the association between PMI and all-cause child mortality in SSA with the use of appropriate comparison groups and adjustments for regional trends in child mortality., In a difference-in-difference analysis, Aleksandra Jakubowski and colleagues show that the introduction of the US President's Malaria Initiative in 19 African countries was associated with a significant reduction in the annual risk of under-5 child mortality., Author summary Why was this study done? Despite the considerable investment the US government has made in the President’s Malaria Initiative (PMI) since 2006, no studies to date have evaluated its association with population health outcomes. Previous evaluations have documented decreasing child mortality and increasing use of key malaria interventions in PMI-recipient countries. Our study sought to determine whether the trends in health outcomes in PMI-recipient countries differed significantly from the trends in these outcomes in PMI non-recipient countries in sub-Saharan Africa (SSA) over the past 2 decades. What did the researchers do and find? We used a study design that leveraged multiple publicly available data sources from countries throughout SSA, spanning the years before and after PMI introduction, in order to estimate association between the introduction of PMI and child mortality rates. Our dataset included 7,752,071 child-year observations from 2,112,951 individual children who lived in 32 sub-Saharan countries, including all 19 PMI countries. We found that after adjusting for baseline differences between countries, overall time trends, other funding sources, and individual characteristics, PMI was associated with 16% annual risk reduction in child mortality and increased population coverage of key malaria prevention and treatment technologies. We tested the robustness of our results with a series of sensitivity analyses. What do these findings mean? The study provides evidence that introduction of PMI was associated with significant reductions in child mortality in SSA, primarily through increased access to malaria prevention technologies. Evidence from this study can be used to inform policy decisions about future funding levels for malaria interventions. The interpretation of our study results rests on the assumption that there were no important unmeasured variables that differentially affected mortality rates in PMI and comparison countries during the study period.

To analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries.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: 2006-2014). 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.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.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.Analyser les facteurs qui affectent les variations de qualité observées concernant les soins prénatals et aux enfants malades dans des établissements de soins primaires de sept pays africains.Nous avons rassemblé des données représentatives à l'échelle nationale provenant d'enquêtes évaluant la qualité des services fournis par des établissements de santé situés au Kenya, au Malawi, en Namibie, en Ouganda, en République-Unie de Tanzanie, au Rwanda et au Sénégal (années couvertes par les enquêtes: 2006-2014). Nous avons créé des indices de qualité du processus pour les soins prénatals (premières visites) et les visites aux enfants malades en nous appuyant sur les protocoles de l'Organisation mondiale de la Santé. À l'aide de différents modèles de régression multiniveaux de qualité pour chaque service, nous avons évalué des facteurs liés aux pays, aux établissements, aux prestataires et aux patients susceptibles d'expliquer les variations qualitatives des soins.Nous avons disposé de données tirées de 2594 observations de consultations cliniques pour des soins prénatals et de 11 402 observations de consultations cliniques pour des enfants malades. Dans l'ensemble, les prestataires de soins de santé ont réalisé en moyenne 62,2% (intervalle interquartile, IQR: de 50,0 à 75,0) des huit actions de soins prénatals recommandées et 54,5% (IQR: de 33,3 à 66,7) des neuf actions de soins aux enfants malades lors des visites observées. Les soins prénatals étaient de meilleure qualité dans les établissements mieux dotés en personnel et mieux équipés et ceux fournis par les médecins et les cliniciens se sont révélés de moins bonne qualité que ceux des infirmiers. Les prestataires expérimentés ainsi que ceux qui exerçaient dans des établissements mieux gérés ont fourni des soins de meilleure qualité aux enfants malades, aucune différence n'ayant été observée entre les médecins ou les infirmiers ou entre les centres de consultation mieux équipés et ceux moins bien équipés. Les établissements privés ont obtenu de meilleurs résultats que les établissements publics. Les différences entre les pays ont davantage permis d'expliquer les variations de qualité que tous les autres facteurs combinés.Deux services de soins primaires essentiels pour les femmes et les enfants se sont révélés de qualité médiocre, celle-ci variant selon les pays et au sein des pays. Une analyse des raisons des variations qualitatives permettrait de définir des stratégies afin d'améliorer les soins.Analizar los factores que afectan a las variaciones de la calidad observada en la atención prenatal y a niños enfermos en centros de atención primaria de siete países africanos.Se recopilaron datos representativos a nivel nacional de encuestas de evaluación sobre prestación de servicios de centros sanitarios de Kenya, Malawi, Namibia, la República Unida de Tanzanía, Rwanda, Senegal y Uganda (rango anual de encuestas: 2006–2014). En base a los protocolos de la Organización Mundial de la Salud, se crearon índices de calidad de procesos para la atención prenatal (primeras consultas) y para las consultas a niños enfermos. Se evaluaron los factores nacionales, de centros, de proveedores y de pacientes que pudieran explicar las variaciones en la calidad de la atención mediante el uso de distintos modelos de regresión en múltiples niveles de calidad para cada servicio.Se disponía de los resultados para 2 594 y 11 402 observaciones de consultas médicas de atención prenatal y atención a niños enfermos, respectivamente. En general, los profesionales sanitarios realizaron una media de 62,2% (rango intercuartílico, ICR: 50,0 a 75,0) de ocho acciones de atención prenatal recomendadas y de 54,5% (ICR: 33,3 a 66,7) de nueve acciones de atención a niños enfermos en las visitas observadas. La calidad de la atención prenatal fue mejor en los centros con mejor personal y mejores equipos e inferior para los médicos y asistentes clínicos que para los enfermeros. Los proveedores con experiencia y aquellos en centros con una mejor gestión ofrecieron una atención a niños enfermos de mejor calidad, sin diferencias entre médicos y enfermeros o entre centros mejor o peor equipados. Los centros privados superaron la calidad de los públicos. Las diferencias entre países tuvieron un papel más influyente a la hora de explicar la varianza en la calidad que el resto de factores juntos.La calidad de dos servicios de atención primaria básicos para mujeres y niños era escasa y diversa entre países y dentro de ellos. El análisis de las razones de las variaciones en la calidad podría identificar estrategias para mejorar la atención.الغرض تحليل العوامل المؤثرة على التباين فيما يخضع للملاحظة من جودة الرعاية المقدمة في مرحلة ما قبل الولادة والرعاية المقدمة للمرضى من الأطفال داخل منشآت الرعاية الأولية في سبع دول أفريقية. الطريقة جمعنا بيانات تمثيلية على المستوى الوطني مستمدة من مسوح تقييمية للمنشآت الصحية من حيث توفير الخدمة في أوغندا وجمهورية تنزانيا المتحدة ورواندا والسنغال وكينيا وملاوي وناميبيا (المدى الزمني لسنوات المسح: 2006-2014). ووفقًا لبروتوكولات منظمة الصحة العالمية، أنشأنا مؤشرات لجودة تدابير الرعاية المقدمة في مرحلة ما قبل الولادة (الزيارات الأولى) والزيارات الخاصة بالمرضى من الأطفال. وقيَّمنا العوامل الوطنية والعوامل المرتبطة بالمنشأة والمرضى والجهات الموفرة للخدمة والتي قد تفسر التباين في مستوى جودة الرعاية المقدمة، حيث استخدمنا نماذج تحوّف منفصلة متعددة المستويات فيما يتعلق بمستوى الجودة لكل نوع من أنواع الخدمات. النتائج كانت البيانات متاحةً بشأن 2594 و11402 من عمليات ملاحظة الاستشارات العلاجية فيما يتعلق بالرعاية المقدمة في مرحلة ما قبل الولادة والمقدمة للمرضى من الأطفال، على التوالي. وإجمالاً، بلغ متوسط تنفيذ جهات توفير الرعاية الصحية للإجراءات الموصى بها 62.2‏% (المدى الربيعي: من 50.0 إلى 75.0) وذلك من إجمالي ثمانية إجراءات موصى بها لتقديم الرعاية في مرحلة ما قبل الولادة، و54.5‏% (المدى الربيعي: من 33.3 إلى 66.7) من إجمالي تسع إجراءات للرعاية في الزيارات التي خضعت للملاحظة. وارتفع مستوى جودة الرعاية المقدمة في مرحلة ما قبل الولادة لدى المنشآت التي تحظى بتجهيزات وفريق عمل أكثر كفاءة، بينما انخفض مستوى الجودة لدى الأطباء والمساعدين الإكلينيكيين مقارنةً بالممرضات. وتولى مقدمو الخدمات الصحية من ذوي الخبرة والعاملون في المنشآت التي تحظى بمستوى أفضل من الإدارة تقديم مستوى أعلى من جودة الرعاية المقدمة للمرضى من الأطفال، دون أي اختلاف بين الأطباء والممرضات أو بين العيادات التي يرتفع فيها مستوى التجهيزات وتلك التي يقل فيها مستوى التجهيزات. وتفوقت المنشآت الخاصة في أدائها على المنشآت الحكومية. ولعبت الاختلافات بين الدول دورًا أكثر فعالية في تفسير التباين في مستوى الجودة مقارنةً بالعوامل الأخرى مجتمعةً. الاستنتاج إن جودة اثنين من أنواع الخدمات الأساسية للرعاية الصحية الأولية المقدمة للنساء والأطفال كانت ضعيفة المستوى ومتباينة فيما بين الدول وفيما بين المناطق داخل الدول. ويمكن أن يؤدي تحليل أسباب التباين في مستوى الجودة إلى تحديد استراتيجيات لتحسين الرعاية المقدمة.旨在分析影响七个非洲国家初级医疗机构中所观测的产前及患儿护理质量的变化的因素。.我们通过肯尼亚、卢旺达、马拉维、纳米比亚、塞内加尔、坦桑尼亚联合共和国和乌干达的卫生设施服务提供评估调查收集了具有全国代表性的数据(调查年份: 2006–2014)。 根据世界卫生组织协议,我们创建了产前护理(初诊)及患儿就诊流程的质量指标。 我们通过各服务质量的独立多级回归模型对可阐明护理质量变化的全国性、设施、提供者及患者因素进行了评估。.数据分别适用于 2594 及 11 402 份产前护理及患儿临床咨询的观测报告。 总体来说,在所观测的就诊期间,八项推荐产前护理行为中,62.2% (四分差,IQR: 50.0 至 75.0)由医疗护理提供者开展;九项患儿护理行为中,54.5% (IQR: 33.3 至 66.7)由医疗护理提供者开展。 人员及设施配备更为齐全出色的机构产前护理质量会更高一些,且医生及临床助理医师提供的产前护理质量低于护士提供的产前护理质量。经验丰富的提供者以及管理良好的机构中的提供者能够提供更高质量的患儿护理,且护理质量在医生及护士之间或设施配备多与少的诊所之间并无差别。 私营机构表现优于公共机构。 国家差异较所有其它因素而言,在阐明质量差异方面更具影响力。.各国妇女及儿童的两项基本初级医疗服务的质量较为薄弱且在国家之间以及国家内部存在差异。 可通过分析质量变化的原因制定改善护理的策略。.Проанализировать факторы, обуславливающие различия в качестве дородового наблюдения и ухода за больными детьми в учреждениях первичной медико-санитарной помощи в семи африканских странах.Авторы объединили репрезентативные на национальном уровне данные обзорных исследований по оценке предоставления услуг в медицинских учреждениях в Кении, Малави, Намибии, Объединенной Республике Танзания, Руанде, Сенегале и Уганде (учитывались обследования, проводимые в 2006–2014 гг.). На основании протоколов Всемирной организации здравоохранения были разработаны показатели качества для дородового наблюдения (первых визитов) и для ухода за больными детьми. Авторы провели оценку национальных факторов, а также факторов, связанных с медицинским центром, поставщиком медицинских услуг и пациентом, которые могли бы объяснить различия в качестве медицинской помощи, используя отдельные многоуровневые регрессионные модели качества для каждой услуги.Были доступны данные для 2594 и 11 402 обзорных исследований клинических консультаций по дородовому уходу и уходу за больными детьми соответственно. Медицинские работники провели в среднем 62,2% (межквартильный размах, МКР: от 50,0 до 75,0) из восьми рекомендуемых мероприятий по дородовому уходу и 54,5% (МКР: от 33,3 до 66,7) из девяти мероприятий по уходу за больными детьми во время посещений, совершенных под наблюдением исследователей. Качество дородового ухода было выше в медицинских учреждениях, которые были лучше укомплектованы персоналом и оборудованием, и ниже у врачей, чем у медсестер. Опытные поставщики медицинских услуг в медицинских учреждениях с лучшей системой управления обеспечивали уход за больными детьми более высокого качества без каких-либо различий между врачами и медсестрами или между клиниками с лучшим и худшим оснащением. Частные медицинские учреждения превзошли общественные медицинские учреждения. Страновые особенности были более значимы при объяснении различий в качестве, чем все остальные факторы, вместе взятые.Качество двух основных услуг первичной медико-санитарной помощи для женщин и детей было низким и варьировалось как между странами, так и внутри отдельной страны. Анализ причин различий в качестве позволил бы определить стратегии для усовершенствования медико-санитарной помощи.

Introduction Measurement of effective coverage (quality-corrected coverage) of essential health services is critical to monitoring progress towards the Sustainable Development Goal for health. We combine facility and household surveys from eight low-income and middle-income countries to examine effective coverage of maternal and child health services. Methods We developed indices of essential clinical actions for antenatal care, family planning and care for sick children from existing guidelines and used data from direct observations of clinical visits conducted in Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania and Uganda between 2007 and 2015 to measure quality of care delivered. We calculated healthcare coverage for each service from nationally representative household surveys and combined quality with utilisation estimates at the subnational level to quantify effective coverage. Results Health facility and household surveys yielded over 40 000 direct clinical observations and over 100 000 individual reports of healthcare utilisation. Coverage varied between services, with much greater use of any antenatal care than family planning or sick-child care, as well as within countries. Quality of care was poor, with few regions demonstrating more than 60% average performance of basic clinical practices in any service. Effective coverage across all eight countries averaged 28% for antenatal care, 26% for family planning and 21% for sick-child care. Coverage and quality were not strongly correlated at the subnational level; effective coverage varied by as much as 20% between regions within a country. Conclusion Effective coverage of three primary care services for women and children in eight countries was substantially lower than crude service coverage due to major deficiencies in care quality. Better performing regions can serve as examples for improvement. Systematic increases in the quality of care delivered—not just utilisation gains—will be necessary to progress towards truly beneficial universal health coverage.

Growing evidence from a number of countries in Asia and Africa documents a large shift towards facility deliveries in the past decade. These increases have not led to the improvements in health outcomes that were predicted by health policy researchers in the past. In light of this unexpected evidence, we have assessed data from multiple sources, including nationally representative data from 43 countries in Asia and Africa, to understand the size and range of changing delivery location in Asia and Africa. We have reviewed the policies, programs and financing experiences in multiple countries to understand the drivers of changing practices, and the consequences for maternal and neonatal health and the health systems serving women and newborns. And finally, we have considered what implications changes in delivery location will have for maternal and neonatal care strategies as we move forward into the next stage of global action. As a result of our analysis we make four major policy recommendations. (1) An expansion of investment in mid-level facilities for delivery services and a shift away from low-volume rural delivery facilities. (2) Assured access for rural women through funding for transport infrastructure, travel vouchers, targeted subsidies for services and residence support before and after delivery. (3) Increased specialization of maternity facilities and dedicated maternity wards within larger institutions. And (4) a renewed focus on quality improvements at all levels of delivery facilities, in both private and public settings.

Three members of PLOS Medicine's editorial board who are leading researchers in implementation science define the characteristics of high-quality studies and invite their submission to the journal.

To evaluate the service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania.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.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.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.Évaluer la disponibilité des services dans les établissements de santé du Bangladesh, d'Haïti, du Kenya, du Malawi, de Namibie, du Népal, d'Ouganda, de République-Unie de Tanzanie, du Rwanda et du Sénégal.En nous appuyant sur les données existantes tirées de l'évaluation de la prestation des services dans les systèmes de santé des 10 pays étudiés, nous avons calculé un indice de disponibilité des services pour chacun des 8443 établissements de santé. Cet indice correspond à la disponibilité en pourcentage de 50 éléments que l'Organisation mondiale de la Santé estime essentiels pour assurer les soins de santé. Dans le cadre de notre analyse, nous avons utilisé entre 37 et 49 éléments de la liste. Nous avons eu recours à une régression linéaire pour évaluer le pouvoir explicatif indépendant de quatre caractéristiques nationales et quatre caractéristiques au niveau des établissements concernant la disponibilité des services établie.Les valeurs moyennes de l'indice de disponibilité des services étaient de 77% pour les 636 hôpitaux et de 52% pour les 7807 centres de santé/dispensaires. L'analyse a révélé des insuffisances particulièrement courantes en matière de médicaments et de capacités de diagnostic. L'indice de disponibilité variait davantage entre les hôpitaux et les centres de santé/dispensaires d'un même pays qu'entre différents pays. Une faible corrélation a été constatée entre les facteurs nationaux liés au financement de la santé et l'indice de disponibilité.La plupart des établissements de santé des pays étudiés n'étaient pas dotés d'équipements suffisants pour prodiguer les soins cliniques de base. Il est nécessaire de prêter davantage attention aux inégalités au sein des pays pour qu'ils renforcent les capacités de leur système de santé en vue d'assurer une couverture universelle.Evaluar la disponibilidad del servicio de los centros sanitarios en Bangladesh, Haití, Kenya, Malawi, Namibia, Nepal, la República Unida de Tanzanía, Rwanda, Senegal y Uganda.Usando los datos existentes de las evaluaciones sobre prestación de servicios de sistemas sanitarios de los 10 países de estudio, se ha calculado un índice de disponibilidad del servicio para cada uno de los 8443 centros sanitarios. El índice representa el porcentaje de disponibilidad de 50 elementos que la Organización Mundial de la Salud considera esenciales para proporcionar atención sanitaria. Para el análisis, se han utilizado entre 37 y 49 de los elementos de la lista. Se ha utilizado la regresión lineal para evaluar el poder independiente descriptivo de cuatro características nacionales y cuatro a nivel del centro sobre la disponibilidad del servicio registrado.Los valores medios del índice de la disponibilidad del servicio fueron del 77% para los 636 hospitales y del 52% para los 7807 centros de salud/clínicas. Las deficiencias en los medicamentos y la capacidad de diagnóstico fueron particularmente comunes. El índice de disponibilidad varió más entre hospitales y centros de salud/clínicas en el mismo país que entre países. Existe una correlación débil entre los factores nacionales relacionados con la financiación sanitaria y el índice de disponibilidad.La mayoría de los centros sanitarios en nuestros países de estudio fueron equipados de forma insuficiente para proporcionar atención sanitaria básica. Si los países van a reforzar la capacidad del sistema sanitario hasta conseguir la cobertura universal, se necesita poner más atención a las desigualdades dentro del país.تقييم جاهزية خدمات المرافق الصحية في بنغلاديش وهايتي وكينيا وملاوي وناميبيا ونيبال ورواندا والسنغال وأوغندا وجمهورية تنزانيا المتحدة.باستخدام البيانات المتاحة من واقع تقييمات تقديم خدمات أنظمة الصحة في بلدان الدراسة العشرة (10)، قمنا بحساب مؤشر جاهزية الخدمة لكل من المرافق الصحية البالغ عددها 8443 مرفقًا. ويمثل هذا المؤشر نسبة التوفر المئوية لخمسين عنصرًا تعتبرها منظمة الصحة العالمية ضرورية لتوفير الرعاية الصحية. واستخدمنا 37-49 من العناصر المدرجة في القائمة لإجراء التحليل الصادر عنا. وقد استخدمنا أسلوب التحوّف الخطي لتقييم القدرة التوضيحية المستقلة لأربع خصائص وطنية وعلى مستوى المرافق الصحية فيما يتعلق بجاهزية الخدمات الواردة في التقارير.بلغت القيم المتوسطة لمؤشر جاهزية الخدمة 77‏٪ لعدد 636 مستشفى و‏52‏٪ لعدد 7807 مراكز صحية وعيادات. وكانت أوجه القصور شائعة في الأدوية والقدرة التشخيصية بوجه خاص. وظهر تباين في مؤشر الجاهزية بشكل أكبر بين المستشفيات والمراكز الصحية/العيادات الموجودة في نفس البلد أكثر مما بينها وبين مثيلاتها في البلدان الأخرى. وكان هناك ارتباط ضعيف بين العوامل الوطنية المتصلة بتمويل الصحة ومؤشر الجاهزية.لم تكن معظم المرافق الصحية في بلدان دراستنا مجهزة تجهيزًا كافيًا لتوفير الرعاية السريرية الأساسية. وإذا ما أرادت البلدان تعزيز قدرة النظام الصحي على تحقيق التغطية الشاملة، فإنه ينبغي إيلاء مزيد من الاهتمام لحالات التفاوت داخل البلدان旨在评估海地、肯尼亚、卢旺达、马拉维、孟加拉国、纳米比亚、尼泊尔、塞内加尔、坦桑尼亚共和国和乌干达卫生机构服务配备状态。.运用从这 10 个研究对象国卫生系统服务提供评估机构提供的现有数据，我们对 8443 个卫生机构的服务配备指数进行了计算。该指数代表 50 个由世界卫生组织认定的医疗保健必要项目的可用情况。 我们选取其中 37–49 个项目进行分析。我们采用线性回归法对服务配备报告上的四个国家级和四个机构级特征的独立阐释能力进行了评估。.其中 636 家医院的服务配备指数平均数是 77%，且 7807 家医疗中心/诊所的平均数为 52%。给药和诊断能力不足尤为普遍。相同国家医院和医疗中心/诊所间的配备指数差异比不同国家间的相应配备指数差异更大。与卫生筹资相关的国家因素和配备指数之间相关性较弱。.我们的研究对象国中，大多数国家的卫生机构在提供基本卫生护理方面配备不足。如果这些国家计划提升卫生系统能力，以实现全民卫生服务，它们需要多关注国内的不公平现象。.Оценить степень готовности медицинских учреждений к оказанию услуг в Бангладеш, Гаити, Кении, Малави, Намибии, Непале, Объединенной Республике Танзания, Руанде, Сенегале и Уганде.Используя имеющиеся данные, полученные из оценок предоставления медицинского обслуживания системами здравоохранения в 10 исследуемых странах, авторы рассчитали индекс готовности к оказанию услуг для каждого из 8443 медицинских учреждений. Этот индекс представляет собой процентный показатель наличия 50 пунктов, которые Всемирная организация здравоохранения считает необходимыми для оказания медицинской помощи. Для анализа авторы использовали от 37 до 49 пунктов из этого списка. Авторы использовали линейную регрессию для оценки степени влияния независимых показателей — четырех характеристик на национальном уровне и четырех характеристик на уровне медицинского учреждения — на заявленную степень готовности к оказанию услуг.Средние значения индекса готовности к оказанию услуг составили 77% для 636 больниц и 52% для 7807 медицинских центров и клиник. Особенно был распространен недостаток медикаментов и диагностического потенциала. Индекс готовности больше варьировался между больницами и медицинскими центрами/клиниками внутри одной страны, чем между разными странами. Наблюдалась слабая корреляция между национальными факторами, связанными с финансированием здравоохранения, и индексом готовности.Большинство медицинских учреждений в исследуемых странах были недостаточно подготовлены для оказания базовой клинической помощи. Если страны будут наращивать потенциал системы здравоохранения в целях обеспечения всеобщего охвата, им следует больше внимания уделять неравенству внутри страны.

Background Quality of healthcare is an important determinant of future progress in global health. However, the distributional aspects of quality of care have received inadequate attention. We assessed whether high quality maternal care is equitably distributed by (1) mapping the quality of maternal care in facilities located in poorer versus wealthier areas of Kenya; and (2) comparing the quality of maternal care available to Kenyans in and not in poverty. Methods We assessed three measures of maternal care quality: facility infrastructure and clinical quality of antenatal care and delivery care, using indicators from the 2010 Kenya Service Provision Assessment (SPA), a standardized facility survey with direct observation of maternal care provision. We calculated poverty of the area served by antenatal or delivery care facilities using the Multidimensional Poverty Index. We used regression analyses and non-parametric tests to assess differences in maternal care quality in facilities located in more and less impoverished areas. We estimated effective coverage with a minimum standard of care for the full population and those in poverty. Results A total of 564 facilities offering at least one maternal care service were included in this analysis. Quality of maternal care was low, particularly clinical quality of antenatal and delivery care, which averaged 0.52 and 0.58 out of 1 respectively, compared to 0.68 for structural inputs to care. Maternal healthcare quality varied by poverty level: at the facility level, all quality metrics were lowest for the most impoverished areas and increased significantly with greater wealth. Population access to a minimum standard (≥0.75 of 1.00) of quality maternal care was both low and inequitable: only 17% of all women and 8% of impoverished women had access to minimally adequate delivery care. Conclusion The quality of maternal care is low in Kenya, and care available to the impoverished is significantly worse than that for the better off. To achieve the national targets of maternal and neonatal mortality reduction, policy initiatives need to tackle low quality of care, starting with high-poverty areas.

Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. We measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania. Using a structured questionnaire, we interviewed women who had delivered in health facilities upon discharge and re-interviewed a randomly selected subset 5-10 weeks later in the community. We calculated frequencies of 14 abusive experiences and the prevalence of any disrespect/abuse. We performed logistic regression to analyse associations between abusive treatment and individual and birth experience characteristics. A total of 1779 women participated in the exit survey (70.6% response rate) and 593 were re-interviewed at home (75.8% response rate). The frequency of any abusive or disrespectful treatment during childbirth was 343 (19.48%) in the exit sample and 167 (28.21%) in the follow-up sample; the difference may be due to courtesy bias in exit interviews. The most common events reported on follow-up were being ignored (N = 84, 14.24%), being shouted at (N = 78, 13.18%) and receiving negative or threatening comments (N = 68, 11.54%). Thirty women (5.1%) were slapped or pinched and 31 women (5.31%) delivered alone. In the follow-up sample women with secondary education were more likely to report abusive treatment (odds ratio (OR) 1.48, confidence interval (CI): 1.10-1.98), as were poor women (OR 1.80, CI: 1.31-2.47) and women with self-reported depression in the previous year (OR 1.62, CI: 1.23-2.14). Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is a health system crisis that requires urgent solutions both to ensure women's right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.

Background Following a protracted civil war, Liberia is rebuilding its health system. One of the aims of reconstruction is to expand access to health care to a previously underserved rural population. Objective This study analysed the determinants of Liberians' confidence in their ability to obtain needed care for themselves or their children in case of serious illness. Methods A cross-sectional survey of 1435 adults in Nimba County, Liberia was conducted. Logistic regression models were estimated with reported ability to obtain needed health services for serious illness as the dependent variable, and demographics, health need, health system characteristics and informal health care as independent variables. Results Overall, 50.56% of respondents reported that they could obtain needed services for themselves or their children. Confidence in the ability to obtain care increased with education [odds ratio (OR) 1.62, 95% confidence interval (CI): 1.19-2.21] and poor physical health in the past 30 days (OR 1.38, 95% CI: 1.01-1.88), and decreased with poverty (OR 0.66, 95% CI: 0.47-0.93), exposure to previous trauma (OR 0.50, 95% CI: 0.36-0.71), dissatisfaction with respondent's last formal health visit (OR = 0.70, 95% CI: 0.54-0.91) and high utilization of the informal health sector (OR = 0.84, 95% CI: 0.73-0.96). No correlation was found between health system confidence and being female, being 35 years old or younger, formal health sector use, being within an hour of a clinic and the closest clinic having basic capabilities. Conclusions Respondents' experiences with the health care system had a greater correlation with their confidence in obtaining needed health care than proximity or quality of medical equipment in health clinics. Despite pro-poor policies guiding health system reconstruction, poor and less educated individuals have less confidence that the health system can meet their health needs.

To measure the extent, determinants and results of bypassing local primary care clinics for childbirth among women in rural parts of the United Republic of Tanzania.Women were selected in 2012 to complete a structured interview from a full census of all 30076 households in clinic catchment areas in Pwani region. Eligibility was limited to those who had delivered between 6 weeks and 1 year before the interview, were at least 15 years old and lived within the catchment areas. Demographic and delivery care information and opinions on the quality of obstetric care were collected through interviews. Clinic characteristics were collected from staff via questionnaires. Determinants of bypassing (i.e. delivery of the youngest child at a health centre or hospital without provider referral) were analysed using multivariate logistic regression. Bypasser and non-bypasser birth experiences were compared in bivariate analyses.Of 3019 eligible women interviewed (93% response rate), 71.0% (2144) delivered in a health facility; 41.8% (794) were bypassers. Bypassing likelihood increased with primiparity (odds ratio, OR: 2.5; 95% confidence interval, CI: 1.9-3.3) and perceived poor quality at clinics (OR: 1.3; 95% CI: 1.0-1.7) and decreased if clinics recently underwent renovations (OR: 0.39; 95% CI: 0.18-0.84) and/or performed ≥ 4 obstetric signal functions (OR: 0.19; 95% CI: 0.08-0.41). Bypassers reported better quality of care on six of seven quality of care measures.Many pregnant women, especially first-time mothers, choose to bypass local primary care clinics for childbirth. Perceived poor quality of care at clinics was an important reason for bypassing. Primary care is failing to meet the obstetric needs of many women in this rural, low-income setting.Mesurer l'ampleur, les déterminants et les résultats du contournement des cliniques locales de soins primaires pour l'accouchement des femmes des régions rurales de la République-Unie de Tanzanie.En 2012, des femmes ont été sélectionnées pour une enquête structurée à partir d'un recensement complet des 30 076 ménages dans les zones d'influence clinique de la région de Pwani. Seules ont été admises les femmes qui avaient accouché 6 semaines à 1 an avant l'enquête, avaient au moins 15 ans et vivaient dans les zones d'influence. Des informations démographiques et sur les soins fournis lors de l'accouchement, ainsi que des avis sur la qualité des soins obstétricaux ont été recueillis dans le cadre d'entrevues. Les caractéristiques cliniques ont été recueillies par le personnel au moyen de questionnaires. Les déterminants du contournement (c'est-à-dire l'accouchement du plus jeune enfant dans un établissement de soins ou à l'hôpital sans recommandation du prestataire de soins) ont été analysés par régression logistique multivariée. Les expériences d'accouchement avec ou sans contournement ont été comparées dans des analyses à deux variables.Sur 3019 femmes admissibles interrogées (taux de réponse de 93%), 71,0% (2144) ont accouché dans un établissement de santé; 41,8% (794) avaient contourné les cliniques. La probabilité de contournement augmentait avec la primiparité (rapport des cotes, CR: 2,5; intervalle de confiance à 95%, IC: 1,9 à 3,3) et la perception de la médiocrité des soins en clinique (CR: 1,3 ; IC à 95%: 1 à 1,7) et elle diminuait si les cliniques avaient récemment effectué des travaux de rénovation (CR: 0,39 ; IC à 95%: 0,18 à 0,84) et/ou effectuaient 4 fonctions de signal obstétrique ou plus (CR: 0,19; IC à 95% 0,08 à 0,41). Une meilleure qualité de 6 des 7 mesures de qualité des soins a été signalée par les femmes contournant les cliniques.De nombreuses femmes enceintes, surtout en cas de première grossesse, choisissent de contourner les cliniques de soins primaires locales pour leur accouchement. La perception de la médiocrité des soins fournis dans les cliniques constitue une importante raison de contournement. Les soins primaires ne répondent pas aux besoins obstétricaux de nombreuses femmes dans les contextes ruraux à bas revenu.Medir la extensión, los factores determinantes y los resultados de prescindir de clínicas locales de atención primaria para el parto entre las mujeres de zonas rurales de Tanzania.En 2012 se seleccionaron las mujeres para completar una entrevista estructurada de un censo completo de todos los 30 076 hogares de las áreas de captación clínica de la región de Pwani. La elegibilidad se limitaba a las mujeres que habían dado a luz entre 6 semanas y 1 año antes de la entrevista, tenían al menos 15 años y vivían dentro de las áreas de captación. Se recogieron las opiniones sobre la calidad de la atención obstétrica e información demográfica y sobre la atención en el parto mediante entrevistas, así como las características de la clínica mediante cuestionarios al personal. Se analizaron los factores determinantes de prescindir de las clínicas (es decir, dar a luz al hijo menor en un centro sanitario o un hospital sin derivación por parte del prestador de salud) mediante regresión logística multivariada. Se compararon las experiencias de nacimiento entre quienes prescindieron y no prescindieron de las clínicas en análisis bivariados.De las 3019 mujeres elegibles que se entrevistaron (tasa de respuesta del 93 %), el 71,0 % (2144) dio a luz en un centro sanitario y el 41,8 % (794) prescindió de las clínicas. La probabilidad de prescindir de las clínicas aumenta con la primiparidad (proporción de probabilidades, OR: 2,5; intervalo de confianza del 95 %, IC: 1,9–3,3) y la percepción de calidad deficiente en las clínicas (OR: 1,3; IC del 95 %: 1,0–1,7). Por otro lado, disminuía si las clínicas se habían renovado recientemente (OR: 0,39; IC del 95 %: 0,18–0,84) y/o realizaban ≥ 4 funciones de señalización obstétrica (OR: 0,19; IC del 95 %: 0,08–0,41). Quienes prescindieron de las clínicas comunicaron una mejor calidad de la atención en seis de siete de las medidas de calidad de la atención.Muchas mujeres embarazadas, sobre todo las madres primerizas, eligen prescindir de las clínicas de atención primaria para dar a luz. La percepción de calidad deficiente de la atención en las clínicas fue un motivo importante para prescindir de las mismas. La atención primaria no logra satisfacer las necesidades obstétricas de muchas mujeres de este entorno rural de bajos ingresos.قياس المدى الخاص بمحددات ونتائج اجتناب عيادات الرعاية الأولية المحلية للولادة بين النساء في المناطق الريفية في جمهورية تنزانيا المتحدة.تم اختيار مجموعة من النساء في عام 2012 لإجراء مقابلة منظمة من بين تعداد كامل لجميع الأسر المعيشية البالغ عددها 30076 أسرة في مناطق مستجمعات العيادات في منطقة بواني. وكانت الأهلية قاصرة على الإناث اللاتي ولدن قبل المقابلة بفترة تتراوح من 6 أسابيع إلى سنة واحدة وكان عمرهن 15 عاماً على الأقل وعشن داخل مناطق المستجمعات. وتم جمع المعلومات الديموغرافية وتلك الخاصة برعاية الولادة والآراء بشأن جودة الرعاية التوليدية من خلال المقابلات. وتم جمع خصائص العيادات من الموظفين عن طريق الاستبيانات. وتم تحليل محددات الاجتناب (أي ولادة الطفل الأصغر في مركز صحي أو مستشفى دون إحالة من مقدمي الخدمات) باستخدام الارتداد اللوجيستي متعدد المتغيرات. وتم مقارنة خبرات الولادة بين الإناث اللاتي اجتنبن عيادات الرعاية الأولية للولادة واللاتي لم يجتنبنها في تحليلات ثنائية المتغيرات.قامت نسبة 71.0 % (2144 سيدة) من إجمالي 3019 سيدة مؤهلة تم إجراء المقابلة معهن (معدل الاستجابة 93 %)، بالولادة في مرفق صحي واجتنب ذلك نسبة 41.8 % (794 امرأة). وازدادت احتمالية الاجتناب مع البكروية (نسبة الاحتمال: 2.5؛ فاصل الثقة 95 %: من 1.9 إلى 3.3) وضعف الجودة الملحوظ في العيادات (نسبة الاحتمال: 1.3؛ فاصل الثقة 95 %: من 1.0 إلى 1.7) وانخفضت في حالة العيادات التي تم تجديدها مؤخراً (نسبة الاحتمال: 0.39؛ فاصل الثقة 95 %: من 0.18 إلى 0.84) و/أو أجرت ما يزيد عن أو يساوي 4 وظائف إشارات توليدية (نسبة الاحتمال: 0.19؛ فاصل الثقة 95 %: من 0.08 إلى 0.41). وأبلغت النساء اللاتي اجتنبن هذه العيادات عن تحسن جودة الرعاية في ست من سبع تدابير خاصة بجودة الرعاية.يختار العديد من النساء الحوامل، ولا سيما الأمهات لأول مرة اجتناب عيادات الرعاية الأولية المحلية في ولادتهن. وكان ضعف جودة الرعاية الملحوظ في العيادات سبباً مهماً في اجتناب هذه العيادات. وتعجز الرعاية الأولية عن تلبية احتياجات الولادة للعديد من النساء في هذه المنطقة الريفية منخفضة الدخل.估测坦桑尼亚联合共和国农村地区妇女分娩绕过本地初级保健诊所的程度、决定因素和结果。在2012年从滨海区诊所病人来源区所有30076户家庭全面人口普查中选择妇女完成结构式访谈。仅在访谈之前6周至1年之间有过生育、至少15岁并居住在来源区的女性才符合纳入资格。通过访谈收集人口统计学和分娩护理信息以及对产科护理质量的看法。通过问卷调查收集诊所特征。使用多元逻辑回归分析绕过诊所（即不经过医务人员转诊而在卫生院或医院生育最小的孩子）的决定因素。在二变量分析中比较绕过者和非绕过者的生育体验。在受访谈的3019名符合调查资格的妇女（93%响应率）中，71.0%（2144）在医疗机构分娩；41.8%（794）为绕过者。初产（优势比，OR：2.5；95%置信区间，CI：1.9–3.3）和感觉诊所服务质量差（OR：1.3；95% CI：1.0–1.7）则绕过可能性增加；如果诊所最近经过翻新（OR：0.39；95% CI：0.18–0.84）和/或执行了 四种或以上的产科信号功能（OR：0.19；95% CI：0.08–0.41）则绕过可能性降低。在七个护理质量的量度中绕过者报告有六个的护理质量更好。很多孕妇（尤其是第一次生产的母亲）选择绕过本地初级医疗诊所进行分娩。感觉初级医疗诊所护理质量差是绕过的主要原因。初级护理未能满足这一农村低收入区域很多女性的产科需求。Количественно оценить степень, детерминанты и результаты отказа рожениц от услуг местных клиник первичной помощи в сельских районах Объединенной Республики Танзании.В 2012 году было выполнено выборочное исследование среди женщин с проведением структурированного интервью на основе полной переписи всех 30 076 домашних хозяйств в районах, приписанных к клиникам первичной медико-санитарной помощи в округе Пвани. В исследовании принимали участие женщины, родившие в период от 6 недель до 1 года до проведения опроса, достигшие 15-летнего возраста и проживающие в районах, приписанных к клиникам. В ходе интервью были собраны данные о демографическом составе рожениц, родильных учреждениях и отзывы женщин о качестве акушерской помощи. Характеристики клиник были получены путем анкетирования персонала. Факторы, определяющие отказ от услуг (т.е. рождение младшего ребенка в медицинском центре или больнице без направления соответствующей клиники), были проанализированы с использованием многомерной логистической регрессии. Опыт рожениц, поступивших по направлению первичных клиник и без такового, сравнивался по методике двумерного анализа.Из 3019 женщин, давших интервью (процент участия 93%), 71,0% (2144) рожали в медицинском учреждении; из них 41,8% (794) поступили не по направлению. Вероятность отказа от услуг первичных клиник возрастала в случаях рождения первого ребенка (отношение рисков, ОР: 2,5; 95% доверительный интервал, ДИ: 1,9–3,3), а также вследствие негативного восприятия качества обслуживания в этих клиниках (ОР: 1,3; 95% ДИ: 1,0–1,7) и уменьшалась, если в клинике недавно был проведен ремонт (ОР: 0,39; 95% ДИ: 0,18–0,84) и/или клиника выполняла не менее 4 акушерских сигнальных функций (ОР: 0,19; 95% ДИ: 0,08–0,41). Роженицы, не имевшие направления, сообщали о лучшем качестве медицинской помощи по шести из семи параметров качества медицинской помощи.Многие беременные женщины, особенно рожающие в первый раз, отказываются от услуг местных клиник первичной помощи. Распространенное мнение о низком качестве медицинской помощи в этих клиниках являлось важной причиной такого выбора. Местные клиники первичной медико-санитарной помощи оказались не в состоянии удовлетворить акушерские потребности многих женщин в этом сельском округе с низкими доходами населения.

Objective To determine the effective coverage of obstetric care in a rural Tanzanian region and to assess differences in effective coverage by wealth. Design Cross-sectional structured interviews. Setting Pwani Region, Tanzania. Participants The study includes 24 rural, government-managed, primary healthcare clinics and their catchment populations. From January–April 2016, we conducted a household survey of a census of women with recent deliveries, health worker knowledge surveys and facility audits. Main Outcome Measures We explored the proportion of women receiving quality care through the cascade and conducted an equity analysis by wealth. Results In total, 2,910 of 3,564 women (81.6%) reported delivering their most recent child in a health facility, 1,096 of whom delivered in a study facility. Using a minimum threshold of quality, the effective coverage of obstetric care was 25%. Quality was lowest in the emergency care dimensions, with the average score on the provider knowledge tests at 47% and the average provision of basic emergency obstetric services below 50%. The wealthiest 20% of women were 4.1 times as likely to deliver in facilities offering at least the minimum threshold of quality care through the cascade compared to the poorest 80% of women (95% confidence interval: 1.5–11.3). Conclusions Effective coverage of delivery care is very low, particularly among poorer women. Health worker knowledge caused the sharpest decline in effective coverage. Measures of effective coverage are a better performance measure of under-resourced health systems than utilization. Equity analyses can further identify important discrepancies in quality across socio-economic levels. Trial Registration ISRCTN 17107760.

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., Sanam Roder-DeWan reveal low levels of quality care in some LMICs based on findings of a survey., Author summary Why was this study done? Expectations of healthcare quality are believed to influence how patients experience and rate healthcare; however, little is known about expectations in low- and middle-income countries (LMICs). High satisfaction with poor-quality care is common in LMICs; one possible explanation is that expectations of care are low. This study was conducted to better understand expectations of healthcare quality in LMICs. What did the researchers do and find? We used an innovative internet sampling methodology to collect information from 17,996 individuals in 12 LMICs. Vignettes describing poor-quality care were used to elicit expectations of healthcare; good ratings for poor-quality care approximate low expectations. Over half of respondents (53%) rated the poor-quality care vignettes as good quality or better; low expectations were more likely if respondents were less educated, were male, reported good personal health, or had experienced discrimination during a healthcare visit in the past. What do these findings mean? Internet users in LMICs are a relatively privileged subgroup in our study countries, limiting the generalizability of our findings. Populations with low expectations are more likely to be satisfied with poor-quality care, reducing the demand-side pressure that health systems experience to deliver high-quality care. Raising expectations of quality may be one approach to improving the quality of healthcare in LMICs.

The fragility of health systems has never been of greater interest—or importance—than at this moment, in the aftermath of the worst Ebola virus disease epidemic to date. The loss of life, massive social disruption, and collapse of even the most basic health-care services shows what happens when a crisis hits and health systems are not prepared. This did not happen only in west Africa— we saw it in Texas too: the struggle to provide a coherent response and manage public sentiment (which often manifests as fear) in a way that ensures that disease does not spread while also allowing day-to-day life to continue. In other words, we saw an absence of resilience. This Viewpoint puts forth a proposed framework for resilient health systems and the characteristics that defi ne them, informed by insights from other fi elds that have embraced resilience as a practice. Health system resilience can be defi ned as the capacity of health actors, institutions, and populations to prepare for and eff ectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it. Health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath. Resilient health systems can also deliver everyday benefi ts and positive health outcomes. This double benefi t—improved performance in both bad times and good—is what has been called “the resilience dividend”. Response to a crisis, be it a disease outbreak or other disruption resulting in a surge of demand for health care (eg, a natural disaster or a mass casualty event) needs both a vigorous public health response and a highly proactive and functioning health-care delivery system. These two systems must work in concert during a crisis—and indeed long before crisis strikes. Health-care systems are complex adaptive systems and resilience is an emergent property of the health system as a whole rather than a single dimension. Building resilience is thus context-dependent and iterative, needing advance assessments of system capacities and weaknesses, investments in vulnerable components of the system before a crisis, reinforcements during the emergency, and review of performance after a crisis. Resilience is not a static construct—for example, the rapid pace of recovery from crisis is a cardinal measure of success. The Ebola epidemic has illustrated that several preconditions for resilience were lacking. The fi rst of these preconditions is recognition of the global nature of severe health crises and clarity about the roles of actors at all levels of the global health system. Although national governments are fundamentally responsible for their health systems, they need the capacity to mobilise the full range of local actors and to rapidly draw on external resources if necessary. The need for a global resilience network is both a moral imperative and a recognition of the fact that pathogens do not respect borders. Shocks to the health system of one country can reverberate across regions and the world. Health system resilience is thus a global public good and needs a collective response from the global community. Funding for this response can come from traditional domestic and donor sources or, as recently suggested, a new international health systems fund to which all countries contribute. A second precondition is a legal and policy foundation to guide the response and establish accountability. The implementation of International Health Regulations, which call on countries to build core public health capacities and establish a means of coordinating a response to health emergencies with regional and global partners, is a prerequisite for eff ective emergency response. Additionally, legislation that clarifi es the authority of public health agencies and the roles and responsibilities of private and public health actors is needed as are policies for involving the private and voluntary sector in the response and allowing fl exibility in sharing and reallocating resources across the health system. Third, there is a need for a strong and committed health workforce, characterised by health personnel who show up for work that might be diffi cult and dangerous. Establishing such a workforce begins with training and deployment of a suffi cient number of doctors, nurses, managers, and outreach workers—a colossal task in a country such as Liberia with a population of 3·5 million people and fewer than 100 doctors—but also building and banking a stock of social capital in the health system before crisis strikes. Just as strong social capital in communities promotes individual psychological resilience after mass trauma, social capital in the health system promotes system-wide recovery from crisis. In the health system context, social capital has two dimensions: a sense of worth, community, and responsibility among health actors (clinicians, managers, engineers, outreach workers) and an inclusive and robust community engagement with the health system. Health systems that earn the trust and support of the population and local political leaders by reliably providing high-quality services before crisis have a powerful resilience advantage. Strong management of district level health systems is key to gaining that trust. Diverse fi elds such as ecology, engineering, complex adaptive systems, psychology, and public health have produced resilience frameworks. The Rockefeller Foundation has developed substantial data about resilient Lancet 2015; 385: 1910–12

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., In a cross-sectional analysis, Hannah Leslie and colleagues examine the association between obstetric facility quality and newborn mortality in Malawi., Author Summary Why Was This Study Done? Large increases in access to health facilities in many low- and middle-income countries (LMIC) have not produced equivalent gains in newborn survival. Little data or evidence on the quality of delivery care in LMICs is currently available, and even less is known on the mortality impact of facility quality. What Did the Researchers Do and Find? We designed and implemented a study of neonatal mortality in Malawi, where facility delivery is highly prevalent and a quality assessment of all health facilities was conducted in 2013–2014. We quantified quality of maternal care at all delivery facilities based on 25 quality characteristics and classified the top 25% of facilities as higher quality. Average quality was low, with particular gaps in infrastructure and performance of basic emergency obstetric care procedures. We linked a nationally representative sample of 6,686 births between November 2011 and March 2014 to their delivery facility and used multivariable linear regression models to estimate the impact of quality on neonatal mortality. To overcome selection issues, we used the relative proximity of higher-quality facilities as an instrument for facility quality. Our empirical results suggest that delivering at a higher-quality facility is associated with a reduction of 23 deaths per 1,000 live births. What Do These Findings Mean? Expanded availability of health facilities does not guarantee access to essential elements of quality maternal and neonatal care. Improvements in facility quality could reduce newborn deaths substantially among women who would receive higher-quality care if it were more accessible.

Objectives The movement of skilled physicians from the public to the private sector is a key constraint to achieving universal health coverage and is currently affecting health systems worldwide. This systematic review aims to assess factors influencing physicians' choice of workplace, and policy interventions for retaining physicians in the public sector. Methods Five literature databases were searched. Studies were included in the review if they focused on at least one of the following criteria: (i) incentives or motivators for retaining physicians in the public sector, (ii) pull factors that encouraged physicians to move to the private sector, (iii) push factors that forced physicians to leave the public sector, (iv) policy interventions or case studies that addressed physician retention in the public sector, and (v) qualitative reviews of policy interventions that were implemented in different health system settings. Results Nineteen articles met the inclusion criteria. Six major themes that affected physicians' choice of workplace were identified including: financial incentives, career development, infrastructure and staffing, professional work environment, workload and autonomy. The majority of the studies suggested that the use of financial incentives was a motivator in retaining physicians in the public sector. The review also identified policy interventions including: regulatory controls, incentives and management reforms. Regulatory controls and incentives were the two most frequently reported policy interventions. Conclusion While factors affecting physicians' choice of workplace are country specific, financial incentives and professional development are core factors. Other factors are highly influenced by context, and thus, it would be useful for future cross-country research to use standardized data collection tools, allowing comparison of contextual factors as well as the examination of how context affects physician retention in the public sector.

Summary In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape.

Summary Background The UN will formulate ambitious Sustainable Development Goals for 2030, including one for health. Feasible goals with some quantifiable, measurable targets can influence governments. We propose, as a quantitative health target, "Avoid in each country 40% of premature deaths (under-70 deaths that would be seen in the 2030 population at 2010 death rates), and improve health care at all ages". Targeting overall mortality and improved health care ignores no modifiable cause of death, nor any cause of disability that is treatable (or also causes many deaths). 40% fewer premature deaths would be important in all countries, but implies very different priorities in different populations. Reinforcing this target for overall mortality in each country are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of tuberculosis, HIV, and malaria deaths; a third of premature deaths from non-communicable diseases (NCDs); and a third of those from other causes (other communicable diseases, undernutrition, and injuries). These challenging subtargets would halve under-50 deaths, avoid a third of the (mainly NCD) deaths at ages 50–69 years, and so avoid 40% of under-70 deaths. To help assess feasibility, we review mortality rates and trends in the 25 most populous countries, in four country income groupings, and worldwide. Methods UN sources yielded overall 1970–2010 mortality trends. WHO sources yielded cause-specific 2000–10 trends, standardised to country-specific 2030 populations; decreases per decade of 42% or 18% would yield 20-year reductions of two-thirds or a third. Results Throughout the world, except in countries where the effects of HIV or political disturbances predominated, mortality decreased substantially from 1970–2010, particularly in childhood. From 2000–10, under-70 age-standardised mortality rates decreased 19% (with the low-income and lower-middle-income countries having the greatest absolute gains). The proportional decreases per decade (2000–10) were: 34% at ages 0–4 years; 17% at ages 5–49 years; 15% at ages 50–69 years; 30% for communicable, perinatal, maternal, or nutritional causes; 14% for NCDs; and 13% for injuries (accident, suicide, or homicide). Interpretation Moderate acceleration of the 2000–10 proportional decreases in mortality could be feasible, achieving the targeted 2030 disease-specific reductions of two-thirds or a third. If achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0–49 years that would be seen in 2030 at 2010 death rates, and about 17 million of the 41 million such deaths at ages 0–69 years. Such changes could be achievable by 2030, or soon afterwards, at least in areas free of war, other major effects of political disruption, or a major new epidemic. Funding UK Medical Research Council, Norwegian Agency for Development Cooperation, Centre for Global Health Research, and Bill & Melinda Gates Foundation.

measures are especially critical given the large scope and increased complexity of health services required. The universal health coverage (UHC) target of the health SDG stipulates that everyone can obtain essential health services at high quality without suffering financial hardship, yet quality has not been widely tracked. 11 There is no benefit to UHC if people are un willing to use services due to the poor quality of the services for which they are financially covered. Even if people are accessing services, poor quality will undermine health outcomes, reducing the value of UHC. Finally, high-quality health services attract the public support that contributes to governments providing sustained financing.

The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. We propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalize civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.La qualité des soins dispensés par les systèmes de santé contribue aux efforts qui visent à atteindre l'objectif de développement durable n°3 sur la santé et le bien-être. De plus en plus d'éléments indiquent que l'impact des interventions dans le domaine de la santé est compromis par une mauvaise qualité des soins dans les pays aux revenus les plus faibles. La qualité des soins sera également cruciale pour la réussite des initiatives en faveur de la couverture sanitaire universelle; il est peu probable que des personnes insatisfaites de la qualité et de l'étendue des services proposés soient favorables au financement public des soins. De plus, l'éthique veut que toutes les personnes, même les plus pauvres, puissent bénéficier d'une prise en charge de qualité minimum qui leur permette de voir leur santé s'améliorer. Or, aujourd'hui, dans les pays à revenu faible et intermédiaire, l'évaluation de la qualité n'est pas à la hauteur de la tâche. Les systèmes d'information sanitaire fournissent des données incomplètes et souvent peu fiables. Quant aux enquêtes menées dans les établissements, elles recueillent trop d'indicateurs à l'utilité discutable, s'intéressent à un nombre limité de services et sont rapidement obsolètes. Les évaluations existantes n'intègrent pas bien le processus de soins et le vécu des patients. Le point de vue des patients sensibles aux pratiques de soins, un élément de base de l'évaluation de la qualité dans les pays à revenu élevé, est rarement recueilli. Nous proposons six recommandations stratégiques afin d'améliorer l'évaluation de la qualité des soins et d'amplifier son impact stratégique: (i) redoubler les efforts pour améliorer et institutionnaliser les systèmes d'enregistrement et de statistiques de l'état civil; (ii) réformer les enquêtes menées dans les établissements et renforcer les systèmes d'information courants; (iii) définir de nouvelles mesures de la qualité pour les régions aux faibles ressources; (iv) recueillir l'avis des patients concernant la qualité; (v) investir dans des données nationales de qualité; et (vi) traduire les données sur la qualité en actions ayant un impact stratégique.La calidad de la atención proporcionada por los sistemas sanitarios contribuye a los esfuerzos para alcanzar el objetivo 3 de desarrollo sostenible en salud y bienestar. Cada vez existen más pruebas de que el impacto de las intervenciones sanitarias se ve desvirtuado por la mala calidad de la atención en países con ingresos bajos. La calidad de la salud también será fundamental para el éxito de las iniciativas de cobertura sanitaria universal; los ciudadanos que no están satisfechos con la calidad y el alcance de los servicios cubiertos no suelen apoyar la financiación pública de la atención sanitaria. Asimismo, existe un ímpetu ético para garantizar que todo el mundo, incluida la población más pobre, obtiene un estándar mínimo de calidad de atención que sea eficaz a la hora de mejorar la salud. No obstante, actualmente la medición de la calidad en países de ingresos bajos y medios no es adecuada para la tarea. Los sistemas de información sanitaria ofrecen información incompleta y a menudo poco fiable, y las encuestas en los centros recopilan demasiados indicadores de servicios públicos inestables, se centran en un número limitado de servicios y quedan obsoletos con mucha rapidez. Las medidas existentes apenas captan el proceso de atención y la experiencia del paciente. Los resultados de los pacientes sensibles a las prácticas de atención sanitaria son un elemento fundamental de la evaluación de la calidad en países con ingresos altos, y apenas se recopilan. Se proponen seis recomendaciones normativas para mejorar la medición de la calidad de la atención y ampliar el impacto de su política: (i) redoblar los esfuerzos para mejorar e institucionalizar los sistemas de registro civil y de estadísticas vitales; (ii) reformar las encuestas de los centros y fortalecer los sistemas de información rutinaria; (iii) crear nuevas medidas de calidad para contextos de pocos recursos; (iv) ofrecer al paciente una perspectiva sobre calidad; (v) invertir en datos de calidad nacionales; y (vi) traducir las pruebas de calidad para lograr un impacto de la política.تساهم الجودة النوعية للرعاية المُقدمة من النظم الصحية في الجهود الرامية للوصول إلى الهدف الثالث (3) للتنمية المستدامة والمتعلق بالصحة والرفاهية. وهناك أدلة متزايدة تشير إلى ضعف دور التدخلات الصحية بسبب تردي الجودة النوعية للرعاية في البلدان ذات الدخل المنخفض. كما ستلعب الجودة النوعية للرعاية دورًا حاسمًا في نجاح مبادرات التغطية الصحية على المستوى العالمي، فليس من المتوقع أن يقوم مواطنون غير راضين عن الجودة النوعية ونطاق الخدمات التي يتم تغطيتها بدعم التمويل العمومي للرعاية الصحية. فضلًا عن ذلك فإن وجود الدافع الأخلاقي يعمل على ضمان حصول جميع الأشخاص – بمن فيهم الأشد فقرًا – على الحد الأدنى من الجودة النوعية للرعاية والتي تعتبر ضرورة لتحسين الحالة الصحية. على الرغم من ذلك فإن مقاييس الجودة النوعية القائمة اليوم في البلدان منخفضة ومتوسطة الدخل تعتبر غير ملائمة لهذا الدور، حيث توفر نظم المعلومات الصحية بيانات غير مكتملة وغالبًا غير موثوقة، وتعمل المسوحات التي تجري في المنشآت الطبية على جمع الكثير والكثير من المؤشرات مُبهمة الفائدة مع تركيز كل اهتمامها على عدد محدود من الخدمات والتي سريعًا ما ستصبح خارج إطار الزمن. كما تعجز المقاييس الحالية عن تناول عملية الرعاية والتجربة التي يعاشها المريض على النحو الأمثل. ونادرًا ما يتم جمع النتائج المتعلقة بالمرضى رغم أهميتها في مجال الممارسات المتبعة للرعاية الصحية ودورها كأساس لتقييم الجودة النوعية في البلدان مرتفعة الدخل. ونحن نقدم ست توصيات للسياسات العامة تهدف إلى تحسين مقياس الجودة النوعية للرعاية وتعظيم تأثيرها، وهي تتمثل في: (1) مضاعفة الجهود للعمل على تحسين نظم التسجيل المدني ونظم الإحصاءات الحيوية وتكريس استخدامها لدى المؤسسات، و(2) تطوير المسوحات المتبعة لدى المنشآت الطبية وتعزيز نظم المعلومات الروتينية، و(3) ابتكار مقاييس جودة جديدة للبيئات شحيحة الموارد، و(4) استطلاع آراء المرضى حول الجودة النوعية للرعاية، و(5) الاستثمار في جمع بيانات ذات جودة نوعية رفيعة على المستوى الوطني، و(6) تفسير مؤشرات الجودة النوعية لتعظيم أثر السياسات العامة.由卫生系统提供的护理质量影响健康与幸福方面的可持续发展目标 3 的实现。 越来越多证据表明，卫生干预措施的影响受到了低收入国家较差护理质量的破坏。 护理质量对于全民卫生覆盖活动的成功同样至关重要；对普及服务的质量及范围不满的市民不可能支持公共医疗保健融资。 此外，道德推力的存在将确保所有人（包括最贫困人员）均可获得可有效改善健康的最低质量标准的护理。 然而，中低收入国家现今的质量衡量结果仍不足以完成该任务。 卫生信息系统提供不完整且通常不可靠的数据，机构调查采集过多用途不确定的指标，专注在有限的服务上并且很快就会过期。 现有量具无法准确收集护理流程及患者体验的数据。 几乎很少收集对医疗保健实践敏感的患者效果，而这一指标是高收入国家质量评估的重要度量。 我们提出了六项政策建议以改善护理衡量的质量并扩大该政策的影响： (i) 加倍努力改善民事登记及生命数据系统，并使其制度化；(ii) 改革机构调查并加强常规信息系统；(iii) 向资源匮乏地区引进新的质量量具；(iv) 获取患者对质量的看法；(v) 投资全国质量数据；以及 (vi) 转化质量证据以获取政策影响。.Качество медицинской помощи, обеспечиваемое системами здравоохранения, вносит свой вклад в усилия по достижению цели 3 в области устойчивого развития, направленной на улучшение здоровья и благополучия. Все больше фактов свидетельствуют о том, что эффект проведения мероприятий в области здравоохранения нивелируется плохим качеством медицинской помощи в странах с низким уровнем дохода. Качество медицинской помощи также будет иметь решающее значение для успеха инициатив по всеобщему охвату услугами систем здравоохранения; граждане, недовольные качеством и содержанием предоставляемых услуг, вряд ли будут поддерживать государственное финансирование здравоохранения. Кроме того, существует этический стимул для гарантии того, что все люди, в том числе самые бедные, смогут получить минимальный стандарт качества медицинского обслуживания, который является эффективным для улучшения состояния здоровья. Тем не менее оценка качества сегодня в странах с низким и средним уровнем дохода является недостаточной для выполнения этой задачи. Информационные системы здравоохранения предоставляют неполные и часто недостоверные данные, а в обследованиях учреждений применяется слишком много показателей неопределенной полезности и уделяется внимание ограниченному ряду услуг. Кроме того, такие обследования быстро устаревают. Существующие оценки отражают процесс медицинского ухода и впечатления пациента не в полной мере. Результаты ведения пациентов, зависящие от принятых методов в сфере здравоохранения и являющиеся основным показателем качества в странах с высоким уровнем дохода, редко собираются. Авторы предлагают шесть рекомендаций в отношении политики, призванных усовершенствовать оценку качества медицинской помощи и усилить эффект этой политики: (i) удвоить усилия по усовершенствованию и официальному закреплению систем регистрации актов гражданского состояния и статистики естественного движения населения; (ii) реорганизовать обследования учреждений и улучшить стандартные информационные системы; (iii) внедрить новые оценки качества для условий ограниченности ресурсов; (iv) взглянуть на качество с точки зрения пациента; (v) инвестировать в данные о качестве на национальном уровне; (vi) использовать фактические данные о качестве для усиления эффекта политики.

To develop a composite measure of primary care quality and apply it to Haiti's primary care system.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.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.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.Élaborer des critères d'évaluation composites de la qualité des soins de santé primaires et les appliquer au système de soins primaires d'Haïti.En utilisant le cadre de laSur les 786 centres de soins primaires recensés en Haïti en 2013, seuls 332 (43%) ont été évalués comme étant de bonne qualité pour le critère «accessibilité des services». Un nombre inférieur de centres ont obtenu un score reflétant une bonne qualité en termes de prestations de services efficaces (30; 4%), de gestion et d'organisation (91; 12%) et de fonctions de soins primaires (43; 5%). Même si à la date de notre étude, près de 91% de la population vivait dans un rayon de 5 km d'un centre de soins primaires, d'après nos estimations, 23% uniquement de la population totale (et même seulement 5% de la population rurale) avait accès à des soins primaires de bonne qualité.Malgré un réseau étendu de centres de santé, à la date de notre étude, seule une proportion relativement faible d'Haïtiens avaient accès à un centre de soins primaires de bonne qualité. Ces centres étaient particulièrement rares dans les zones rurales. Des analyses systématiques similaires de la qualité des soins primaires pourraient éclairer les efforts nationaux menés pour renforcer les systèmes de santé.Desarrollar una medida compuesta de la calidad de la atención primaria y aplicarla al sistema de atención primaria de Haití.Utilizando el marco de la Iniciativa de Mejora del Desempeño de la Atención Primaria de la Salud, se definieron cuatro dominios de la prestación de servicios de atención primaria: (i) cuidado accesible; (ii) prestación eficaz de servicios; (iii) gestión y organización; y (iv) funciones de atención primaria. Cada centro de atención primaria de Haití recibió una calificación de calidad para cada dominio y, en general, las calificaciones de calidad escasa, regular y buena se indicaron con calificaciones de 0,00–0,49, 0,50–0,74 y 0,75–1,00 respectivamente. Se cuantificó el acceso y el acceso efectivo a la atención primaria según las proporciones de población en 5 kilómetros de cualquier centro de atención primaria y un buen centro, respectivamente.De los 786 centros de atención primaria en Haití en 2013, únicamente 332 (43%) se clasificaron como buenos para atención accesible. Hubo menos centros clasificados como buenos en los dominios de la prestación eficaz de servicios (30; 4%), gestión y organización (91; 12%) y funciones de atención primaria (43; 5%). A pesar de que el 91% de la población vivía en un radio de 5 kilómetros de un centro de atención primaria, únicamente un 23% estimado de toda la población (incluido el 5% de la población rural) tenía acceso a atención primaria de buena calidad.A pesar de una extensa red de centros sanitarios, únicamente una minoría de los haitianos tenía acceso a un centro de atención primaria de buena calidad. Dichos centros eran especialmente escasos en zonas rurales. Un análisis sistemático similar de la calidad de la atención primaria podría informar sobre los esfuerzos nacionales para fortalecer los sistemas sanitarios.وضع معيار مركب لجودة الرعاية الأولية وتطبيقه على نظام الرعاية الأولية في هايتي.قمنا بتعريف أربعة نطاقات تقديم خدمات الرعاية الأولية باستخدام إطار عمل مبادرة أداء الرعاية الصحية الأولية: (1) الرعاية التي يمكن الوصول إليها، و(2) تقديم الخدمات الفعّالة، و(3) الإدارة والتنظيم، و(4) وظائف الرعاية الأولية. نقوم بمنح كل مرفق رعاية أولية في هايتي نقاط جودة لكل نطاق وبصورة شاملة، وتتم الإشارة إلى الجودة السيئة، والمعقولة والجيدة من خلال النقاط 0.00-0.49، و0.50-0.74، و0.75-1.00 على التوالي. كما حددنا مقدار الوصول والوصول الفعال إلى الرعاية الأولية باعتبارها نسب القطاعات السكانية خلال 5 كيلو مترات من أي مرفق رعاية أولية ومرفق جيد، بالتتابع.من 786 مرفق رعاية في هايتي سنة 2013، لم يتم تصنيف إلا 332 (43‏%) مرفقًا كمرفق جيد للرعاية التي يمكن الوصول إليها. وتم تصنيف عدد أقل من المنشآت باعتبارها منشآت جيدة في ضوء نطاقات تقديم الخدمات الفعّالة (30، 4‏%) والتنظيم والإدارة (91، 12‏%)، ووظائف الرعاية الأولية (43، 5‏%). بالرغم من أن حوالي 91‏% من القطاعات السكانية تعيش ضمن 5 كيلو مترات من مرفق الرعاية الأولية، فلا تتوفر سبل الوصول إلى رعاية أولية بجودة نوعية جيدة إلا لما يقدر بنسبة 23‏% من إجمالي السكان، بما في ذلك ‏5‏% من سكان الريف.بالرغم من وجود شبكة واسعة من المرافق الصحية، فإن أقلية من سكان هايتي يمكنهم الوصول إلى مرفق رعاية أولية بجودة جيدة. وكانت المرافق من هذا النوع شحيحة على نحوٍ خاص في المناطق الريفية. ويمكن الاعتماد على التحاليل المنهجية المشابهة لجودة الرعاية الأولية كأساس للمعلومات المقدمة لإفادة الجهود القومية الرامية إلى تعزيز أنظمة الرعاية الصحية.旨在制定一种综合评估初级医疗质量的方法,并将之应用到海地初级医疗系统中。.我们利用初级卫生保健实施方案 (Primary Health Care Performance Initiative) 的框架,对提供初级医疗服务的四个领域进行了定义: (i) 可及性服务;(ii) 提供有效服务;(iii)管理和组织;以及 (iv) 初级医疗功能。 我们分别从每个领域及整体上对海地的各个初级医疗机构的质量进行了评估,其中 0.00–0.49 表示“质量差”,0.50–0.74 表示“质量中等”,0.75–1.00 表示“质量良好”。 我们分别量化了距离全部初级医疗机构和优质机构 5 公里以内人口中获得及有效获得初级医疗服务者的比例。.在 2013 年,在可及性服务方面,海地的 786 个初级医疗机构中仅有 332(43%) 个被列入“良好”等级。 在提供有效服务 (30; 4%)、管理和组织 (91; 12%) 以及初级医疗功能 (43; 5%) 领域,被列入“良好”等级的机构更少。 尽管约 91% 的人口住在距离初级医疗机构 5 公里范围以内,但是据估计,全部人口中仅有 23% (包括 5% 农村人口)能够获得优质的初级医疗服务。.尽管海地拥有广泛的卫生设施网络,但只有少数海地人能够获得优质的初级医疗服务。 在农村地区,此类设施尤为缺乏。 对初级医疗的质量进行类似的系统化分析有助于海地加强卫生系统建设。.Разработать обобщенный показатель качества первичной помощи и применить его для системы первичной медико-санитарной помощи на Гаити.Используя основные принципы Инициативы по эффективной первичной медико-санитарной помощи (ИЭПМСП), авторы определили четыре аспекта оказания услуг первичной медико-санитарной помощи: 1) доступность медицинской помощи; 2) эффективность оказания услуг; 3) управление и организация; 4) функции первичной медико-санитарной помощи. Авторы оценили качество каждого учреждения первичной медико-санитарной помощи на Гаити по каждому аспекту и в целом в баллах: результат от 0,00 до 0,49 балла означал плохое качество, результат от 0,50 до 0,74 балла — среднее, результат от 0,75 до 1,00 балла — хорошее. Доступность и эффективная доступность первичной медико-санитарной помощи оценивались количественно как доля населения, проживающая в радиусе 5 км от любого учреждения первичной медико-санитарной помощи и от учреждения, качество которого, согласно оценке, было хорошим, соответственно.В 2013 году из 786 учреждений первичной медико-санитарной помощи на Гаити только 332 (43%) были отнесены к хорошим с точки зрения доступности медицинской помощи. Меньшее количество учреждений было отнесено к хорошим с точки зрения эффективности оказания услуг (30; 4%), управления и организации (91; 12%) и функций первичной медико-санитарной помощи (43; 5%). Хотя около 91% населения проживало в радиусе 5 км от учреждений первичной медико-санитарной помощи, согласно подсчетам, только 23% от всего населения, включающие лишь 5% сельского населения, имели доступ к первичной медико-санитарной помощи хорошего качества.Несмотря на развитую сеть учреждений здравоохранения, меньшая часть гаитян имела доступ к учреждениям первичной медико-санитарной помощи хорошего качества. Особый недостаток таких учреждений наблюдался в сельской местности. С помощью сходных систематических анализов качества первичной медико-санитарной помощи можно было бы получить информацию для проведения мероприятий по укреплению систем здравоохранения на национальном уровне.

There is growing interest in the use of incentives to increase the utilisation of maternal health services globally, including the use of in-kind goods. As part of the Saving Mothers, Giving Life (SMGL) programme, pregnant women in three districts in Uganda were incentivised to deliver in a facility by the promise of 'Mama Kits' - clean delivery kits augmented with goods for newborns. We collected and analysed qualitative data from 18 focus groups (130 women) who had a recent home (N = 9) or facility delivery (N = 9 groups) to understand their overall perceptions of the SMGL programme, and, in particular, the Mama Kit. There was a high level of awareness of Mama Kits among women who delivered in a health facility and a moderate awareness among women who delivered at home. When available, kits positively affected women's perceptions of facility delivery because they associated availability of kits with affordability of care. When not available, women's perceptions of their actual or expected delivery experience were negatively affected. When well implemented, in-kind goods can be important complements in broader efforts to incentivise facility delivery. Inconsistent implementation and an underestimation of their influence on care-seeking can undermine efforts to reduce maternal mortality and morbidity.

In its report Global Health 2035, the Commission on Investing in Health proposed that health investments can reduce mortality in nearly all low- and middle-income countries to very low levels, thereby averting 10 million deaths per year from 2035 onward. Many of these gains could be achieved through scale-up of existing technologies and health services. A key instrument to close this gap is policy and implementation research (PIR) that aims to produce generalizable evidence on what works to implement successful interventions at scale. Rigorously designed PIR promotes global learning and local accountability. Much greater national and global investments in PIR capacity will be required to enable the scaling of effective approaches and to prevent the recycling of failed ideas. Sample questions for the PIR research agenda include how to close the gap in the delivery of essential services to the poor, which population interventions for non-communicable diseases are most applicable in different contexts, and how to engage non-state actors in equitable provision of health services in the context of universal health coverage., Kruk and colleagues examine the emerging field of policy and implementation research, the scientific enterprise aimed at closing "the delivery gap"—the gap between the interventions known to be effective and what is actually being delivered.

Introduction Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. Methods Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambezia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. Results 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. Conclusions Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.

Background: In sub-Saharan Africa, the capacity of human resources for health (HRH) managers to create positive practice environments that enable motivated, productive, and high-performing HRH is weak. We implemented a unique approach to examining HRH management practices by comparing perspectives offered by mid-level providers (MLPs) of emergency obstetric care (EmOC) in Tanzania to those presented by local health authorities, known as council health management teams (CHMTs). Methods: This study was guided by the basic strategic human resources management (SHRM) component model. A convergent mixed-method design was utilized to assess qualitative and quantitative data from the Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers project. Survey data was obtained from 837 mid-level providers, 83 of whom participated in a critical incident interview whose aim was to elicit negative events in the practice environment that induced intention to leave their job. HRH management practices were assessed quantitatively in 48 districts with 37 members of CHMTs participating in semi-structured interviews. Results: The eight human resources management practices enumerated in the basic SHRM component model were implemented unevenly. On the one hand, members of CHMTs and mid-level providers agreed that there were severe shortages of health workers, deficient salaries, and an overwhelming workload. On the other hand, members of CHMTs and mid-level providers differed in their perspectives on rewards and allocation of opportunities for in-service training. Although written standards of performance and supervision requirements were available in most districts, they did not reflect actual duties. Members of CHMTs reported high levels of autonomy in key HRH management practices, but mid-level providers disputed the degree to which the real situation on the ground was factored into job-related decision-making by CHMTs. Conclusions: The incongruence in perspectives offered by members of CHMTs and mid-level providers points to deficient HRH management practices, which contribute to poor practice environments in acute obstetric settings in Tanzania. Our findings indicate that members of CHMTs require additional support to adequately fulfill their HRH management role. Further research conducted in low-income countries is necessary to determine the appropriate package of interventions required to strengthen the capacity of members of CHMTs.

Globalisation is a defining economic and social trend of the past several decades. Globalisation affects health directly and indirectly and creates economic and health disparities within and across countries. The political response to address these disparities, exemplified by the Millennium Development Goals, has put pressure on the global community to redress massive inequities in health and other determinants of human capability across countries. This, in turn, has accelerated a transformation in the architecture of global health governance. The entrance of new actors, such as private foundations and multi-stakeholder initiatives, contributed to a doubling of funds for global health between 2000 and 2010. Today the governance of public health is in flux, with diminished leadership from multilateral institutions, such as the WHO, and poor coherence in policy and programming that undermines the potential for sustainable health gains. These trends pose new challenges and opportunities for global public health, which is centrally concerned with identifying and addressing threats to the health of vulnerable populations worldwide.

HIV programs in lower-income countries have provided lifesaving care and treatment to millions of people, but their expansion has raised concerns that these programs may have diverted health workers, management attention, and infrastructure investments from other health priorities, such as high maternal mortality in sub-Saharan Africa. We assessed the effect of HIV programs supported by the President's Emergency Plan for AIDS Relief (PEPFAR) on maternal health services for women not infected with HIV in 257 health facilities in eight African countries in 2007-11. Controlling for other variables, we found that having more patients on antiretroviral treatment and HIV-related infrastructure investments, such as on-site laboratories at health clinics, were associated with more deliveries at health facilities by women not infected with HIV. This association is consistent with the hypothesis that PEPFAR-funded infrastructure may also support other health services and that the program may have laid the foundation for improving health system performance in maternal health overall. We recommend that lessons learned from the rapid expansion of HIV services in sub-Saharan Africa should be drawn on to increase the provision of maternal and newborn health care and other high-priority health services, such as the treatment of diabetes, hypertension, and other chronic, noncommunicable diseases.

In low- and middle-income countries, health care systems are an important means by which individuals interact with their government. As such, aspects of health systems in these countries may be associated with public trust in government. Greater trust in government may in turn improve governance and government effectiveness. We identify health system and non – health system factors hypothesized to be associated with trust in government and fit several multilevel regression models to cross-national data from 51,300 respondents in thirty-eight low- and middle-income countries participating in the World Health Surveys. We find that health system performance factors are associated with trust in government while controlling for a range of non – health system covariates. Taken together, higher technical quality of health services, more responsive service delivery, fair treatment, better health outcomes, and financial risk protection accounted for a 13 percentage point increase in the probability of having trust in government. Health system performance and good governance may be more inter-related than previously thought. This finding is particularly important for low-income and fragile states, where health systems and governments tend to be weakest. Future research efforts should focus on determining the causal mechanisms that underlie the observed associations between health system performance and trust in government.

objective To characterise the population that presents to the Accident and Emergency Centre (AEC) at Komfo Anokye Teaching Hospital (KATH) and to identify risk factors associated with bypassing proximal care facilities. methods A structured questionnaire was verbally administered to patients presenting to the AEC over 2 weeks. The questionnaire focused on the use of health care resources and characteristics of current illness or injury. Measures recorded include demographics, socioeconomic status, chief complaint, transportation and mobility, reasons for choosing KATH and health care service utilisation and cost. results The total rate of bypassing proximal care was 33.9%. On multivariate analysis, factors positively associated with bypassing included age older than 38 years (OR: 2.18, P 0.04) and prior visits to facility (OR 2.88, P 0.01). Bypassers were less likely to be insured (OR 0.31, P 0.01), to be seeking care due to injury (OR 0.42, P 0.03) and to have previously sought care for the problem (OR 0.10, P < 0.001). conclusions Patients who bypass facilities near them to seek care at an urban AEC in Ghana do so for a combination of reasons including familiarity with the facility, chief complaint and insurance status. Understanding bypassing behaviour is important for guiding health care utilisation policy decisions and streamlining cost-effective, appropriate access to care for all patients.

Concern that HIV programs in low-income countries may strain weak health systems and undermine achievement of other priority health goals has resulted in a research agenda focused on measuring the effects of past HIV investments on non-HIV services and outcomes. However, this research has limited value for informing future health policies and programs, which increasingly view health systems as the common platform for delivery of HIV and other health services. These policies reflect a shift in the framing of HIV care and treatment from emergency response to routine health service. In this paradigm, relevant areas for research are strengthening, scaling, and sustaining health systems in low-income countries to reduce all-cause mortality and morbidity, including deaths from HIV. To build an evidence base to support current and future health systems and policy, researchers need to move from retrospective studies to prospective research and adopt innovative study designs and analytic methods.

Background Liberia is rebuilding its health system after a lengthy civil war in which traditional health care was the only reliable source of care. Objective This study explored individual, village, and health system factors related to the utilization of health clinics versus informal providers (eg, healers, medicine sellers) in Liberia. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES: This was a cross-sectional population-representative survey of 1435 adults living in rural Nimba County, Liberia. Participants were asked about past year visits to traditional and formal health care providers and demographics, health, and trauma indicators. The association between formal and informal visits and potential determinants was estimated in separate models using generalized estimating equations to adjust for village-level clustering. Results The median number of visits in the past year to formal and informal providers was 3 and 10, respectively. Clinic visits increased with younger age and female sex, past trauma exposure, the number of traditional healers, and the presence of a facility dispenser. Frequency of informal visits increased with poor self-reported mental and physical health, the presence of facility fees and decreased with literacy and wealth and satisfaction with the formal health system. Conclusions Rural Liberians use both formal and informal health care extensively and as complements rather than substitutes. The reliance on traditional medicine to address health needs is of concern in a country with a high disease burden. Health system investments that build public confidence in the health system may help shift demand from informal to formal health care.

OBJECTIVE. To quantify the influence of health system attributes, particularly quality of care, on preferences for health clinics in Liberia, a country with a high burden of disease that is rebuilding its health system after 14 years of civil war. DATA SOURCES/STUDY SETTING. Informed by focus group discussions, a discrete choice experiment (DCE) was designed to assess preferences for structure and process of care at health clinics. The DCE was fielded in rural, northern Liberia as part of a 2008 population-based survey on health care utilization. DATA COLLECTION. The survey response rate was 98 percent with DCE data available for 1,431 respondents. Mixed logit models were used to estimate the influence of six attributes on choice of hypothetical clinics for a future illness. PRINCIPAL FINDINGS. Participants' choice of clinic was most influenced by provision of a thorough physical exam and consistent availability of medicines. Respectful treatment and government (versus NGO) management marginally increased utility, whereas waiting time was not significant. CONCLUSIONS. Liberians value technical quality of care over convenience, courtesy, and public management in selecting clinics for curative care. This suggests that investments in improved competence of providers and availability of medicines may increase population utilization of essential services as well as promote better clinical outcomes.

The effort to increase access to emergency and surgical care in low-income countries has received global attention. While most of the literature on this issue focuses on workforce challenges, it is critical to recognize infrastructure gaps that hinder the ability of health systems to make emergency and surgical care a reality.This study reviews key barriers to the provision of emergency and surgical care in sub-Saharan Africa using aggregate data from the Service Provision Assessments and Demographic and Health Surveys of five countries: Ghana, Kenya, Rwanda, Tanzania and Uganda. For hospitals and health centres, competency was assessed in six areas: basic infrastructure, equipment, medicine storage, infection control, education and quality control. Percentage of compliant facilities in each country was calculated for each of the six areas to facilitate comparison of hospitals and health centres across the five countries.The percentage of hospitals with dependable running water and electricity ranged from 22% to 46%. In countries analysed, only 19-50% of hospitals had the ability to provide 24-hour emergency care. For storage of medication, only 18% to 41% of facilities had unexpired drugs and current inventories. Availability of supplies to control infection and safely dispose of hazardous waste was generally poor (less than 50%) across all facilities. As few as 14% of hospitals (and as high as 76%) among those surveyed had training and supervision in place.No surveyed hospital had enough infrastructure to follow minimum standards and practices that the World Health Organization has deemed essential for the provision of emergency and surgical care. The countries where these hospitals are located may be representative of other low-income countries in sub-Saharan Africa. Thus, the results suggest that increased attention to building up the infrastructure within struggling health systems is necessary for improvements in global access to medical care.