Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries

Abstract

ObjectiveAssess the quality of healthcare across African countries based on health providers’ clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage.MethodsWith nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme.ResultsAcross all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers’ absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively.ConclusionOur findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers’ absenteeism would only modestly increase the average care readiness that meets minimum quality standards.

The impact of health worker absenteeism on patient health care seeking behavior, testing and treatment: A longitudinal analysis in Uganda

“…The high rate of health worker absenteeism we found is consistent with prior evidence on public health worker absenteeism in sub-Saharan African countries [7][8][9]. Our estimates of absenteeism are somewhat lower than found in previous studies.…”

“…One cornerstone of a functioning health system is reliable access to care, meaning that health facilities are open and staffed with health workers during the expected days and hours. Empirical studies have shown very high levels of health workers not being present at facilities in low and middle-income countries (LMICs), with on average 30 to 40 percent of health facility staff being absent on days when researchers come for unannounced visits [7][8][9][10][11][12]. In the sub-Saharan African countries of Uganda, Kenya and Togo, absence rates of nearly 50% have been found [7].…”

Appropriateness of Care for Common Childhood Infections at Low-Level Private Health Facilities in a Rural District in Western Uganda

“…A community inquiry carried out in the same region and central Uganda as well as Mali also identified mismanagement as cause of deaths among newborns [53]. A recent research policy working paper by the World Bank highlighted the lack of clinical knowledge as a major barrier to quality care provided by health facilities in 10 African countries including Uganda [54].…”

Readiness to provide child health services in rural Uttar Pradesh, India: mapping, monitoring and ongoing supportive supervision

“…This intervention utilized government systems and improvements were seen in multiple domains including infrastructure, data use, clinicals services and medical equipment and were sustained for two years after intensive support was provided. Recently published evaluations looking specifically at pediatric quality of care in facilities in low-and middle income countries use data from the World Bank Service Delivery Indicators or an expanded version of the Service Provision Assessment; however, they are cross-sectional and focus only on the outpatient clinical areas [ 23 , 24 ]. In one study, 42 % of facilities were stocked with at least one type of medication relevant to four service areas and only 70 % had all three pieces of essential medical equipment [ 23 ].…”

“…Recently published evaluations looking specifically at pediatric quality of care in facilities in low-and middle income countries use data from the World Bank Service Delivery Indicators or an expanded version of the Service Provision Assessment; however, they are cross-sectional and focus only on the outpatient clinical areas [ 23 , 24 ]. In one study, 42 % of facilities were stocked with at least one type of medication relevant to four service areas and only 70 % had all three pieces of essential medical equipment [ 23 ]. Cross-sectional assessments are vital as they identify what domains need strengthening and look at potential associations among different aspects of quality of care.…”