Background As coronavirus disease 2019 (COVID-19) spreads, weak health systems must not become a vehicle for transmission through poor infection prevention and control practices. We assessed the compliance of health workers with infection prevention and control practices relevant to COVID-19 in outpatient settings in Tanzania, before the pandemic.Methods This study was based on a secondary analysis of cross-sectional data collected as part of a randomised controlled trial in private for-profit dispensaries and health centres and in faith-based dispensaries, health centres, and hospitals, in 18 regions. We observed provider-patient interactions in outpatient consultation rooms, laboratories, and dressing rooms, and categorised infection prevention and control practices into four domains: hand hygiene, glove use, disinfection of reusable equipment, and waste management. We calculated compliance as the proportion of indications (infection risks) in which a health worker performed a correct action, and examined associations between compliance and health worker and facility characteristics using multilevel mixed-effects logistic regression models. FindingsBetween Feb 7 and April 5, 2018, we visited 228 health facilities, and observed at least one infection prevention and control indication in 220 facilities (118 [54%] dispensaries, 66 [30%] health centres, and 36 [16%] hospitals). 18 710 indications were observed across 734 health workers (49 [7%] medical doctors, 214 [29%] assistant medical officers or clinical officers, 106 [14%] nurses or midwives, 126 [17%] clinical assistants, and 238 [32%] laboratory technicians or assistants). Compliance was 6•9% for hand hygiene (n=8655 indications), 74•8% for glove use (n=4915), 4•8% for disinfection of reusable equipment (n=841), and 43•3% for waste management (n=4299). Facility location was not associated with compliance in any of the infection prevention and control domains. Facility level and ownership were also not significantly associated with compliance, except for waste management. For hand hygiene, nurses and midwives (odds ratio 5•80 [95% CI 3•91-8•61]) and nursing and medical assistants (2•65 [1•67-4•20]) significantly outperformed the reference category of assistant medical officers or clinical officers. For glove use, nurses and midwives (10•06 [6•68-15•13]) and nursing and medical assistants (5•93 [4•05-8•71]) also significantly outperformed the reference category. Laboratory technicians performed significantly better in glove use (11•95 [8•98-15•89]), but significantly worse in hand hygiene (0•27 [0•17-0•43]) and waste management (0•25 [0•14-0•44] than the reference category. Health worker age was negatively associated with correct glove use and female health workers were more likely to comply with hand hygiene.Interpretation Health worker infection prevention and control compliance, particularly for hand hygiene and disinfection, was inadequate in these outpatient settings. Improvements in provision of supplies and health worker behaviours are urgently needed ...

Standardized patients (SPs), i.e. mystery shoppers for healthcare providers, are increasingly used as a tool to measure quality of clinical care, particularly in low- and middle-income countries where medical record abstraction is unlikely to be feasible. The SP method allows care to be observed without the provider’s knowledge, removing concerns about the Hawthorne effect, and means that providers can be directly compared against each other. However, their undercover nature means that there are methodological and ethical challenges beyond those found in normal fieldwork. We draw on a systematic review and our own experience of implementing such studies to discuss six key steps in designing and executing SP studies in healthcare facilities, which are more complex than those in retail settings. Researchers must carefully choose the symptoms or conditions the SPs will present in order to minimize potential harm to fieldworkers, reduce the risk of detection and ensure that there is a meaningful measure of clinical care. They must carefully define the types of outcomes to be documented, develop the study scripts and questionnaires, and adopt an appropriate sampling strategy. Particular attention is required to ethical considerations and to assessing detection by providers. Such studies require thorough planning, piloting and training, and a dedicated and engaged field team. With sufficient effort, SP studies can provide uniquely rich data, giving insights into how care is provided which is of great value to both researchers and policymakers.

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Overprovision—healthcare whose harm exceeds its benefit—is of increasing concern in low- and middle-income countries, where the growth of the private-for-profit sector may amplify incentives for providing unnecessary care, and achieving universal health coverage will require efficient resource use. Measurement of overprovision has conceptual and practical challenges. We present a framework to conceptualize and measure overprovision, comparing for-profit and not-for-profit private outpatient facilities across 18 of mainland Tanzania’s 22 regions. We developed a novel conceptualization of three harms of overprovision: economic (waste of resources), public health (unnecessary use of antimicrobial agents risking development of resistant organisms) and clinical (high risk of harm to individual patients). Standardized patients (SPs) visited 227 health facilities (99 for-profit and 128 not-for-profit) between May 3 and June 12, 2018, completing 909 visits and presenting 4 cases: asthma, non-malarial febrile illness, tuberculosis and upper respiratory tract infection. Tests and treatments prescribed were categorized as necessary or unnecessary, and unnecessary care was classified by type of harm(s). Fifty-three percent of 1995 drugs prescribed and 43% of 891 tests ordered were unnecessary. At the patient-visit level, 81% of SPs received unnecessary care, 67% received care harmful to public health (prescription of unnecessary antibiotics or antimalarials) and 6% received clinically harmful care. Thirteen percent of SPs were prescribed an antibiotic defined by WHO as ‘Watch’ (high priority for antimicrobial stewardship). Although overprovision was common in all sectors and geographical regions, clinically harmful care was more likely in for-profit than faith-based facilities and less common in urban than rural areas. Overprovision was widespread in both for-profit and not-for-profit facilities, suggesting considerable waste in the private sector, not solely driven by profit. Unnecessary antibiotic or antimalarial prescriptions are of concern for the development of antimicrobial resistance. Option for policymakers to address overprovision includes the use of strategic purchasing arrangements, provider training and patient education.