Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania

Abstract

ObjectiveTo analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries.MethodsWe 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.FindingsData 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.ConclusionThe 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.

Clinical performance among recent graduates in nine low‐ and middle‐income countries

“…For example, performance on these core items is only slightly better than on more demanding metrics of performance (i.e. adherence to guidelines) in antenatal care, and even lower in sick child care . Overall, quality of care is worse for sick child care compared to antenatal care or family planning services .…”

“…adherence to guidelines) in antenatal care, and even lower in sick child care . Overall, quality of care is worse for sick child care compared to antenatal care or family planning services . This study benefits from the use of large, nationally representative samples or censuses that included direct observations of care for multiple provider and service types, allowing for comparison of quality performance both within and across countries.…”

“…We developed the Good Medical Practice Index (GMPI) to assess the minimum clinical performance in assessing the patient that is essential for making a diagnosis and proposing correct management and that is expected of all clinicians providing clinical care across visit types (Figure and Appendix Table A2). The GMPI was developed using previous quality indices and service‐specific clinical guidelines . It includes 28 basic clinical activities across antenatal care (ten items), family planning care (eight items) and sick child care (ten items) based on items asked in all Service Provision Assessment surveys matched with existing clinical guidelines.…”

“…However, poor quality may limit the beneficial impacts of UHC, particularly in low‐ and middle‐income countries (LMICs), where baseline quality standards are often not met. Evidence indicates that overall quality of care is low and varies both across and within countries, even for basic maternal and child health services . To reap the benefits of increased coverage, commensurate improvements in quality are required.…”

Content of Care in 15,000 Sick Child Consultations in Nine Lower‐Income Countries

“…Private facilities performed better for antenatal and sick childcare after adjustment for staff and infrastructure in a study of seven sub‐Saharan African countries (Kruk et al. ). Haiti and Nepal were the only study countries where physicians provided a substantial amount of the care; however, physicians did not perform better than associate clinicians and nurses in these countries.…”