ObjectivesTo assess the competence of primary healthcare (PHC) providers in delivering maternal and child nutrition services at the PHC level and patients’ experience in receiving the recommended components of care.DesignObservational cross-sectional analysis.SettingHealthcare facilities in low/middle-income countries (LMICs) with available service provision assessment surveys (Afghanistan (2018), Democratic Republic of Congo (2018), Haiti (2017), Kenya (2010), Malawi (2013–2014), Namibia (2009), Nepal (2015), Rwanda (2007), Senegal (2018), Tanzania (2015) and Uganda (2007).Participants18 644 antenatal visits and 23 262 sick child visits in 8458 facilities across 130 subnational areas in 11 LMICs from 2007 to 2019.Outcomes(1) Provider competence assessed as the direct observations of actions performed during antenatal care (ANC) and sick child visits; and (2) patients’ experience defined as the self-reported awareness of the nutrition services received during ANC and sick child visits and provider effectiveness in delivering these services.ResultsExcept for DRC, all countries scored below 50% on patients’ experience and provider competence. More than 70% of clients were advised on taking iron supplements during pregnancy; however, less than 32% of patients were advised on iron side effects in all the studied countries. Across all countries, providers commonly took anthropometric measurements of expectant mothers and children; however, such assessments were rarely followed up with advice or counselling about growth patterns. In addition, less than 20% of observed providers advised on early/immediate breast feeding in all countries with available data.ConclusionThe 11 assessed countries demonstrated the delivery of limited nutrition services; nonetheless, the apparent deficiency in the extent and depth of questions asked for the majority of tracer activities revealed significant opportunities for improving the quality of nutrition service delivery at the PHC level.

ObjectivesTo examine the capacity and quality of maternal and child health (MCH) services at the subnational primary healthcare (PHC) level in 12 low-income and middle-income countries (LMICs) and its association with intermediate health outputs such as coverage and access to care.DesignObservational cross-sectional study using matched subnational data from service provision assessment surveys and demographic health surveys from 2007 to 2019.Settings138 subnational areas with available survey data in 12 LMICs (Afghanistan, Bangladesh, Democratic Republic of Congo, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania and Uganda).OutcomesEight intermediate MCH outcomes/outputs were explored: (1) met need for family planning by modern methods; (2) attendance of four or more antenatal care visits; (3) perceived financial barriers to care; (4) perceived geographical barriers to care; (5) diphtheria-pertussis-tetanus (DPT) third dose coverage; (6) DPT dropout-rate; (7) care-seeking for pneumonia; and (8) oral rehydration solutions coverage.ResultsOverall, moderate-to-poor PHC performance was observed across the 12 countries, with substantial heterogeneity between the different subnational areas in the same country as well as within the same subnational area across both capacity and quality subdomains. The analysis of the relationship between PHC service delivery and child health outcomes revealed that recent supervision (b=0.34, p<0.01) and supervisors’ feedback (b=0.28, p<0.05) were each associated with increased care-seeking for pneumonia. We also observed the associations of several measures of capacity and quality with DPT immunisation. The analysis of maternal health outcomes yielded only a few statistically significant results at p<0.05 level, however, none remained significant after adjusting for other covariates.ConclusionThe results of this analysis illustrate the heterogeneity in the capacity and quality of PHC service delivery within LMICs. Countries seeking to strengthen their PHC systems could improve PHC monitoring at the subnational level to better understand subnational bottlenecks in service delivery.

Background: Despite a global movement to strengthen primary health care systems, quality of care often remains poor across low-and-middle-income countries. A key determinant for quality of care is provider competence. This scoping review specifically aims to build on the Health Care Provider Performance Review (HCPPR), a systematic review of interventions to improve health care performance in low-and-middle-income countries, by identifying the approaches, effect, and characteristics of successful provider competence interventions at the PHC level. Methods: PubMed, Scopus, and Embase were used to search for peer-reviewed publications and grey literature that reported evidence of interventions to improve provider competence in PHC settings in LMICs. Results: A total of 37 articles met the inclusion criteria. Three themes were identified: education and training, supervision and mentorship, and protocols and tools. Most studies included in the review took place in Sub-Saharan Africa (60 %) and in lower-middle income countries (57 %). Among the 37 articles, 27 (73 %) utilized an education and training intervention, 18 (48 %) utilized a supervision and mentoring intervention, and 15 (41 %) utilized a protocol and tool intervention. A total of 19 (51%) interventions were multicomponent, containing more than one intervention theme. Most interventions reported positive outcomes, although few presented evidence on the long-term impacts of the interventions. Among the three themes, education and training interventions reported more successful interventions compared to supervision and mentoring or protocol and tool-based interventions. Multicomponent interventions reported the most favorable outcomes compared to independent interventions. Conclusion: Provider competence interventions, when appropriately planned, implemented, and sustained are effective for improving the skills, knowledge, and competence of providers in LMICs. When feasible, interventions that combine multiple approaches consistently show to have the greatest short- and long-term effects on the competence of providers. However, despite the available research, there is still a lack of evidence on adapting, implementing, and sustaining interventions to improve provider competence across contexts.

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