Research Article: Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries

Date Published: December 12, 2017

Publisher: Public Library of Science

Author(s): Hannah H. Leslie, Zeye Sun, Margaret E. Kruk, Lars Åke Persson

Abstract: BackgroundIt 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 findingsService 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.ConclusionInputs 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.

Partial Text: The first decade of the 2000s saw a dramatic increase in global health activity, with double-digit increases in international development assistance for health [1], reflecting the global focus on the HIV epidemic and intensified efforts to meet the Millennium Development Goals (MDGs) [2]. Two lessons learned in the pursuit of the health MDGs have particular salience for the current effort to achieve Sustainable Development Goal (SDG) 3: ensuring healthy lives and promoting well-being for all at all ages [3]. First, measurement can drive progress. With the assistance of several global initiatives, including the Countdown to 2015 and the Global Burden of Disease Study, countries closely tracked and compared population coverage of essential health services. As a result, remarkable global and national increases in coverage of services such as facility-based delivery and measles vaccination were achieved [2]. Improvements in health-related indicators that were MDG targets outstripped those in non-MDG targets by nearly 2-fold [4]. Second, for many conditions, increased access to care is insufficient to improve population health when care is of poor quality. In areas such as maternal and newborn health, studies from India, Malawi, and Rwanda have demonstrated that expanded access to formal healthcare has failed to yield survival benefits [5–7]. It is increasingly apparent that the path to achievement of SDG 3 will require similar attention to the measurement and improvement of healthcare quality as the MDG era brought to healthcare access [8,9].

Of 8,501 facilities selected, 8,254 (97.1%) were assessed; 4,354 facilities had at least one valid observation in the selected services (32,531 total observations). The analytic sample comprised 1,407 facilities for ANC, 1,842 for family planning, 227 for delivery, and 4,038 for sick-child care. Because observations were sampled based on availability of patients on the day of visit, facilities excluded from the analysis were disproportionately smaller clinics and health centers. Hospitals made up approximately 25% of the sample for ANC, family planning, and sick-child care and 71% of the facilities for delivery care (Table 1). Approximately 27% of facilities were privately managed, ranging from 22% in family planning to 30% in sick-child care. The number of observations per facility varied from 3.42 in ANC to 4.71 in sick-child care.

Across multiple clinical services in 8 countries, correlation between inputs and adherence to evidence-based care guidelines was weak: within each service, facilities with similar levels of infrastructure provided widely varying care. Observed clinical quality tended to be more variable and lower than infrastructure in nearly all countries and services, suggesting that using inputs as a proxy for quality of care as delivered would be both unreliable and systematically biased to overstate quality. These results were based on a sample stripped of likely outliers (facilities with a single observation of clinical care per service) in order to minimize noise in the association of inputs and process quality. Even in these generally larger facilities, gaps in readiness to provide essential care and particularly in observed clinical quality were evident in all services and countries. Although inputs to care should serve as an essential foundation for high-quality care, these data did not suggest the existence of a minimum threshold of inputs necessary for providing better care within the range of infrastructure observed here. It is possible that such a threshold exists at extremely low levels of facility infrastructure.



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