Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda.

BACKGROUND: Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally. METHODS: We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions. RESULTS: Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level. CONCLUSION: Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.

Examining the influence of health sector coordination on the efficiency of county health systems in Kenya.

BACKGROUND: Health systems are complex, consisting of multiple interacting structures and actors whose effective coordination is paramount to enhancing health system goals. Health sector coordination is a potential source of inefficiency in the health sector. We examined how the coordination of the health sector affects health system efficiency in Kenya. METHODS: We conducted a qualitative cross-sectional study, collecting data at the national level and in two purposely selected counties in Kenya. We collected data using in-depth interviews (n = 37) with national and county-level respondents, and document reviews. We analyzed the data using a thematic approach. RESULTS: The study found that while formal coordination structures exist in the Kenyan health system, duplication, fragmentation, and misalignment of health system functions and actor actions compromise the coordination of the health sector. These challenges were observed in both vertical (coordination within the ministry of health, within the county departments of health, and between the national ministry of health and the county department of health) and horizontal coordination mechanisms (coordination between the ministry of health or the county department of health and non-state partners, and coordination among county governments). These coordination challenges are likely to impact the efficiency of the Kenyan health system by increasing the transaction costs of health system functions. Inadequate coordination also impairs the implementation of health programmes and hence compromises health system performance. CONCLUSION: The efficiency of the Kenyan health system could be enhanced by strengthening the coordination of the Kenyan health sector. This can be achieved by aligning and harmonizing the intergovernmental and health sector-specific coordination mechanisms, strengthening the implementation of the Kenya health sector coordination framework at the county level, and enhancing donor coordination through common funding arrangements and integrating vertical disease programs with the rest of the health system. The ministry of health and county departments of health should also review internal organizational structures to enhance functional and role clarity of organizational units and staff, respectively. Finally, counties should consider initiating health sector coordination mechanisms between counties to reduce the fragmentation of health system functions across neighboring counties.

Management of human resources for health: implications for health systems efficiency in Kenya.

BACKGROUND: Human resources for health consume a substantial share of healthcare resources and determine the efficiency and overall performance of health systems. Under Kenya's devolved governance, human resources for health are managed by county governments. The aim of this study was to examine how the management of human resources for health influences the efficiency of county health systems in Kenya. METHODS: We conducted a case study using a mixed methods approach in two purposively selected counties in Kenya. We collected data through in-depth interviews (n = 46) with national and county level HRH stakeholders, and document and secondary data reviews. We analyzed qualitative data using a thematic approach, and quantitative data using descriptive analysis. RESULTS: Human resources for health in the selected counties was inadequately financed and there were an insufficient number of health workers, which compromised the input mix of the health system. The scarcity of medical specialists led to inappropriate task shifting where nonspecialized staff took on the roles of specialists with potential undesired impacts on quality of care and health outcomes. The maldistribution of staff in favor of higher-level facilities led to unnecessary referrals to higher level (referral) hospitals and compromised quality of primary healthcare. Delayed salaries, non-harmonized contractual terms and incentives reduced the motivation of health workers. All of these effects are likely to have negative effects on health system efficiency. CONCLUSIONS: Human resources for health management in counties in Kenya could be reformed with likely positive implications for county health system efficiency by increasing the level of funding, resolving funding flow challenges to address the delay of salaries, addressing skill mix challenges, prioritizing the allocation of health workers to lower-level facilities, harmonizing the contractual terms and incentives of health workers, and strengthening monitoring and supervision.

Healthcare clinic and pharmacy chains in Kenya and Nigeria: A qualitative exploration of the opportunities and risks they present for healthcare regulatory systems.

BACKGROUND: Regulating fragmented healthcare markets is a major challenge in low- and middle-income countries. Although a recent transformation towards consolidation could improve regulatory efficiency, there are concerns over risks to client safety and market functioning. We investigated market consolidation through the emergence of clinic and pharmacy chains in Kenya and Nigeria and explored resultant regulatory opportunities and risks. METHODS: The study was conducted in Nairobi Kenya and Abuja Nigeria. Data were collected through document reviews and 26 interviews with chain operators, professional associations and regulators between September and December 2018. A thematic analysis was conducted. RESULTS: We characterised two broad types of chains: organic chains that started as single business locations and expanded gradually, and investor-driven chains that expanded rapidly following external capital injection. In both countries, chains and independents were regulated similarly, with regulators failing to both capitalize on opportunities and guard against risks. For instance, chains' brand visibility and centralised management systems made them easier to regulate and more suitable for self-regulation. On the other hand, chains were perceived to pose the risks of market dominance, commercialisation of healthcare, and regulatory capture. CONCLUSION: As healthcare chains expand, regulators should build on opportunities presented and guard against emerging risks.

Level and determinants of county health system technical efficiency in Kenya: two stage data envelopment analysis.

BACKGROUND: Improving health system efficiency is a key strategy to increase health system performance and accelerate progress towards Universal Health Coverage. In 2013, Kenya transitioned into a devolved system of government granting county governments autonomy over budgets and priorities. We assessed the level and determinants of technical efficiency of the 47 county health systems in Kenya. METHODS: We carried out a two-stage data envelopment analysis (DEA) using Simar and Wilson's double bootstrap method using data from all the 47 counties in Kenya. In the first stage, we derived the bootstrapped DEA scores using an output orientation. We used three input variables (Public county health expenditure, Private county health expenditure, number of healthcare facilities), and one outcome variable (Disability Adjusted Life Years) using 2018 data. In the second stage, the bias corrected technical inefficiency scores were regressed against 14 exogenous factors using a bootstrapped truncated regression. RESULTS: The mean bias-corrected technical efficiency score of the 47 counties was 69.72% (95% CI 66.41-73.01%), indicating that on average, county health systems could increase their outputs by 30.28% at the same level of inputs. County technical efficiency scores ranged from 42.69% (95% CI 38.11-45.26%) to 91.99% (95% CI 83.78-98.95%). Higher HIV prevalence was associated with greater technical inefficiency of county health systems, while higher population density, county absorption of development budgets, and quality of care provided by healthcare facilities were associated with lower county health system inefficiency. CONCLUSIONS: The findings from this analysis highlight the need for county health departments to consider ways to improve the efficiency of county health systems. Approaches could include prioritizing resources to interventions that will reduce high chronic disease burden, filling structural quality gaps, implementing interventions to improve process quality, identifying the challenges to absorption rates and reforming public finance management systems to enhance their efficiency.

Analysing the Efficiency of Health Systems: A Systematic Review of the Literature.

BACKGROUND: Efficiency refers the use of resources in ways that optimise desired outcomes. Health system efficiency is a priority concern for policy makers globally as countries aim to achieve universal health coverage, and face the additional challenge of an aging population. Efficiency analysis in the health sector has typically focused on the efficiency of healthcare facilities (hospitals, primary healthcare facilities), with few studies focusing on system level (national or sub-national) efficiency. We carried out a thematic review of literature that assessed the efficiency of health systems at the national and sub-national level. METHODS: We conducted a systematic search of PubMed and Google scholar between 2000 and 2021 and a manual search of relevant papers selected from their reference lists. A total of 131 papers were included. We analysed and synthesised evidence from the selected papers using a thematic approach (selecting, sorting, coding and charting collected data according to identified key issues and themes). FINDINGS: There were more publications from high- and upper middle-income countries (53%) than from low-income and lower middle-income countries. There were also more publications focusing on national level (60%) compared to sub-national health systems' efficiency. Only 6% of studies used either qualitative methods or mixed methods while 94% used quantitative approaches. Data envelopment analysis, a non-parametric method, was the most common methodological approach used, followed by stochastic frontier analysis, a parametric method. A range of regression methods were used to identify the determinants of health system efficiency. While studies used a range of inputs, these generally considered the building blocks of health systems, health risk factors, and social determinants of health. Outputs used in efficiency analysis could be classified as either intermediate health service outputs (e.g., number of health facility visits), single health outcomes (e.g., infant mortality rate) or composite indices of either intermediate outputs of health outcomes (e.g., Health Adjusted Life Expectancy). Factors that were found to affect health system efficiency include demographic and socio-economic characteristics of the population, macro-economic characteristics of the national and sub-national regions, population health and wellbeing, the governance and political characteristics of these regions, and health system characteristics. CONCLUSION: This review highlights the limited evidence on health system efficiency, especially in low- and middle-income countries. It also reveals the dearth of efficiency studies that use mixed methods approaches by incorporating qualitative inquiry. The review offers insights on the drivers of the efficiency of national and sub-national health systems, and highlights potential targets for reforms to improve health system efficiency.

Examining the influence of budget execution processes on the efficiency of county health systems in Kenya.

Public financial management (PFM) processes are a driver of health system efficiency. PFM happens within the budget cycle which entails budget formulation, execution and accountability. At the budget execution phase, budgets are implemented by spending as planned to generate a desired output or outcome. Understanding how the budget execution processes influence the use of inputs and the outcomes that result is important for maximizing efficiency. This study sought to explain how the budget execution processes influence the efficiency of health systems, an area that is understudied, using a case study of county health systems in Kenya. We conducted a concurrent mixed methods case study using counties classified as relatively efficient (n = 2) and relatively inefficient (n = 2). We developed a conceptual framework from a literature review to guide the development of tools and analysis. We collected qualitative data through document reviews and in-depth interviews (n = 70) with actors from health and finance sectors at the national and county level. We collected quantitative data from secondary sources, including budgets and budget reports. We analysed qualitative data using the thematic approach and carried out descriptive analyses on quantitative data. The budget execution processes within counties in Kenya were characterized by poor budget credibility, cash disbursement delays, limited provider autonomy and poor procurement practices. These challenges were linked to an inappropriate input mix that compromised the capacity of county health systems to deliver health-care services, misalignment between county health needs and the use of resources, reduced staff motivation and productivity, procurement inefficiencies and reduced county accountability for finances and performance. The efficiency of county health systems in Kenya can be enhanced by improving budget credibility, cash disbursement processes, procurement processes and provider autonomy.

Budget monitoring, accountability practices and their influence on the efficiency of county health systems in Kenya.

Public Finance Management (PFM) practices influence the attainment of health system goals. PFM processes are implemented within the budget cycle which entails the formulation, execution, and monitoring of government budgets. Budget monitoring and accountability actors, structures, and processes are important in improving the efficiency of health systems. This study examined how the budget monitoring and accountability processes influence the efficiency of county health systems in KenyaWe conducted a qualitative case study of four counties in Kenya selected based on their relative technical efficiency. We collected data using in-depth interviews with health and finance stakeholders (n = 70), and document reviews. We analyzed data using a thematic approach, informed by our study conceptual framework. We found that weak budget monitoring and accountability mechanisms compromised county health system efficiency by a) weakening the effective implementation of the budget formulation and execution steps of the budget cycle, b) enabling the misappropriation of public resources, and c) limiting evidence-informed decision-making by weakening feedback that would be provided by effective monitoring and accountability. Devolution meant that accountability actors were closer to implementation actors which promoted timely problem solving and the relevance of solutions. Internal audit practices were supportive and provided useful feedback to health system managers that facilitated improvements in budget formulation and execution. The efficiency of county health systems can be improved by strengthening the budget monitoring and accountability processes. This can be achieved by increasing the population's budget literacy, supporting participatory budgeting, synchronizing performance and financial accountability, implementing the existent budget monitoring and accountability mechanisms, rewarding efficiency, and sanctioning inefficiency.

The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya.

The financing of public health facilities influences their performance. A key feature that defines health facility financing is the degree of financial autonomy. Understanding the factors that influence public health facility financial autonomy is pertinent to developing strategies to addressing challenges that arise from constrained autonomy. In this paper, we apply a complexity lens to draw on a body of research that we have conducted in Kenya over the past decade, from the onset of devolution reforms, to unpack the determinants of public health facility financial autonomy in a context of decentralisation and provide suggestions for pertinent considerations when designing interventions to address financial autonomy challenges. We find that the factors that affect public health facility autonomy are not only structural, but also procedural, and political and interact in complex ways. These factors include; the public finance management (PFM) laws, sense-making by actors in the health system, political interests in control over resources, subnational level PFM capacity, PFM implementation bottlenecks and broader operational autonomy. Drawing from this analysis, we recommend that efforts at resolving public health facility financial autonomy include: PFM capacity development for subnational levels of government in decentralised settings, the use of a political lens that recognises interests and seeks to align incentives in engagement and solution finding for health facility financial autonomy, the audit of PFM processes to establish and resolve implementation bottlenecks that impinge on public health facility autonomy, and the resolution of operational autonomy to as a facilitator of financial autonomy.

Understanding the performance of county health service delivery in Kenya: a mixed-method analysis.

To better understand the wide variation of performance among county health systems in Kenya, this study investigated their performance determinants. We selected five counties with varied performance and examined their performance across five domains containing 10 thematic areas. We conducted a stakeholder analysis, consisting of focus group discussions and key informant interviews, and administered a quantitative survey to quantify the magnitude of inefficiency. The study found that a shortage of funding was one of the most common complaints from counties, leading to inefficiency in the health system. Another major reason for inefficiencies was the delay in disbursing funding to health facilities, which affected the procurement of medical supplies and commodities essential for delivering healthcare to the population. In addition, lack of autonomy in procuring commodities and equipment was repeatedly mentioned as a barrier to delivering quality health services. Other reported common concerns contributing to the performance of county health systems were the lack of lab tests and equipment, low willingness to join health insurance, rigid procurement policies and lengthy procurement process, lack of motivation and incentives for service delivery, and poor economic status. Despite the common concerns among the five counties, they differed in some schematic areas, such as the county's commitment to health and community mobilization. In summary, this study suggests various factors that determine county health system performance. Given the multifaceted nature of inefficiency drivers, it is necessary to adopt a holistic approach to address the causes of inefficiencies and improve the county health systems.

Performance assessment of the county healthcare systems in Kenya: a mixed-methods analysis.

INTRODUCTION: A well performing public healthcare system is necessary for Kenya to continue progress towards universal health coverage (UHC). Identifying actionable measures to improve the performance of the public healthcare system is critical to progress towards UHC. We aimed to measure and compare the performance of Kenya's public healthcare system at the county level and explore remediable drivers of poor healthcare system performance. METHODS: Using administrative data from fiscal year 2014/2015 through fiscal year 2017/2018, we measured the technical efficiency of 47 county-level public healthcare systems in Kenya using stochastic frontier analysis. We then regressed the technical efficiency measure against a set of explanatory variables to examine drivers of efficiency. Additionally, in selected counties, we analysed surveys and focus group discussions to qualitatively understand factors affecting performance. RESULTS: The median technical efficiency of county public healthcare systems was 84% in fiscal year 2017/2018 (with an IQR of 79% to 90%). Across the four fiscal years of data, 27 out of the 47 Kenyan counties had a declining technical efficiency score. Our regression analysis indicated that impediments to the flow of funding-measured by the budget absorption rate which is the ratio between funds spent and funds released-were significantly related to poor healthcare system performance. Our analysis of interviews and surveys yielded a similar conclusion as nearly 50% of respondents indicated issues stemming from poor budget absorption were significant drivers of poor healthcare system performance. CONCLUSION: Public healthcare systems at the county-level in Kenya general performed well; however, addressing delays in the flow of funding is a concrete step to improve healthcare system performance. As Kenya-and other countries-provides additional funding to meet their UHC goals, establishing a strong and robust public financial management system is critical to ensure that the benefits of UHC are realised.

Examining health sector stakeholder perceptions on the efficiency of county health systems in Kenya.

Efficiency gains is a potential strategy to expand Kenya's fiscal space for health. We explored health sector stakeholders' understanding of efficiency and their perceptions of the factors that influence the efficiency of county health systems in Kenya. We conducted a qualitative cross-sectional study and collected data using three focus group discussions during a stakeholder engagement workshop. Workshop participants included health sector stakeholders from the national ministry of health and 10 (out 47) county health departments, and non-state actors in Kenya. A total of 25 health sector stakeholders participated. We analysed data using a thematic approach. Health sector stakeholders indicated the need for the outputs and outcomes of a health system to be aligned to community health needs. They felt that both hardware aspects of the system (such as the financial resources, infrastructure, human resources for health) and software aspects of the system (such as health sector policies, public finance management systems, actor relationships) should be considered as inputs in the analysis of county health system efficiency. They also felt that while traditional indicators of health system performance such as intervention coverage or outcomes for infectious diseases, and reproductive, maternal, neonatal and child health are still relevant, emerging epidemiological trends such as an increase in the burden of non-communicable diseases should also be considered. The stakeholders identified public finance management, human resources for health, political interests, corruption, management capacity, and poor coordination as factors that influence the efficiency of county health systems. An in-depth examination of the factors that influence the efficiency of county health systems could illuminate potential policy levers for generating efficiency gains. Mixed methods approaches could facilitate the study of both hardware and software factors that are considered inputs, outputs or factors that influence health system efficiency. County health system efficiency in Kenya could be enhanced by improving the timeliness of financial flows to counties and health facilities, giving health facilities financial autonomy, improving the number, skill mix, and motivation of healthcare staff, managing political interests, enhancing anticorruption strategies, strengthening management capacity and coordination in the health sector.

When technology precedes regulation: the challenges and opportunities of e-pharmacy in low-income and middle-income countries.

The recent growth of medicine sales online represents a major disruption to pharmacy markets, with COVID-19 encouraging this trend further. While e-pharmacy businesses were initially the preserve of high-income countries, in the past decade they have been growing rapidly in low-income and middle-income countries (LMICs). Public health concerns associated with e-pharmacy include the sale of prescription-only medicines without a prescription and the sale of substandard and falsified medicines. There are also non-health-related risks such as consumer fraud and lack of data privacy. However, e-pharmacy may also have the potential to improve access to medicines. Drawing on existing literature and a set of key informant interviews in Kenya, Nigeria and India, we examine the e-pharmacy regulatory systems in LMICs. None of the study countries had yet enacted a regulatory framework specific to e-pharmacy. Key regulatory challenges included the lack of consensus on regulatory models, lack of regulatory capacity, regulating sales across borders and risks of over-regulation. However, e-pharmacy also presents opportunities to enhance medicine regulation-through consolidation in the sector, and the traceability and transparency that online records offer. The regulatory process needs to be adapted to keep pace with this dynamic landscape and exploit these possibilities. This will require exploration of a range of innovative regulatory options, collaboration with larger, more compliant businesses, and engagement with global regulatory bodies. A key first step must be ensuring that national regulators are equipped with the necessary awareness and technical expertise to actively oversee this e-pharmacy activity.

Using rubber stamps and mobile phones to help understand and change antibiotic prescribing behaviour in private sector primary healthcare clinics in Kenya.

BACKGROUND: Antibiotic use in primary care can drive antimicrobial resistance (AMR) in the community. However, our understanding of antibiotic prescribing in low- and middle-income countries (LMICs) stems mostly from hospital-based studies or prescription/sales records, with little information available on routine primary care practices. We used an innovative, paper-to-digital documentation approach to deliver routine data and understand antibiotic use for common infections in low-resource primary healthcare clinics (PHCs). METHODS: Rubber stamps were introduced in nine private sector PHCs serving Nairobi's informal settlements to 'print-on-demand' clinical documentation templates into paper charts. The intervention included one mobile phone per PHC to take and share images of filled templates, guideline compilation booklets and monthly continuing medical education (CME) sessions. Templates for upper respiratory tract (URTI), urinary tract (UTI), sexually transmitted (STI) and gastrointestinal infection (GI) management were used in eight PHCs. Information in templates from 889 patient encounters was digitised from smartphone images, analysed, and fed back to clinicians during monthly CME sessions. UTI charts (n=130 and 96, respectively) were audited preintervention and postintervention for quality of clinical documentation and management. RESULTS: Antibiotics were prescribed in 94.3%±1.6% of all patient encounters (97.3% in URTI, 94.2% in UTI, 91.6% in STI and 91.3% in GI), with 1.4±0.4 antibiotics prescribed per encounter. Clinicians considered antibiotic use appropriate in only 58.6% of URTI and 47.2% of GI cases. While feedback did not affect the number of antibiotics prescribed for UTIs, the use of nitrofurantoin, an appropriate, narrow-spectrum antibiotic, increased (9.2% to 29.9%; p<0.0001) and use of broad spectrum quinolones decreased (30.0% to 16.1%; p<0.05). CONCLUSION: Antibiotic use for common infections is high in private sector PHCs in Kenya, with both knowledge and 'know-do' gaps contributing to inappropriate prescription. Paper-based templates in combination with smartphone technologies can sustainably deliver routine primary care case management data to support the battle against AMR.

Rubber stamp templates for improving clinical documentation: A paper-based, m-Health approach for quality improvement in low-resource settings.

BACKGROUND: The United Nations' Sustainable Development Goal #3.8 targets 'access to quality essential healthcare services'. Clinical practice guidelines are an important tool for ensuring quality of clinical care, but many challenges prevent their use in low-resource settings. Monitoring the use of guidelines relies on cumbersome clinical audits of paper records, and electronic systems face financial and other limitations. Here we describe a unique approach to generating digital data from paper using guideline-based templates, rubber stamps and mobile phones. INTERVENTION: The Guidelines Adherence in Slums Project targeted ten private sector primary healthcare clinics serving informal settlements in Nairobi, Kenya. Each clinic was provided with rubber stamp templates to support documentation and management of commonly encountered outpatient conditions. Participatory design methods were used to customize templates to the workflows and infrastructure of each clinic. Rubber stamps were used to print templates into paper charts, providing clinicians with checklists for use during consultations. Templates used bubble format data entry, which could be digitized from images taken on mobile phones. Besides rubber stamp templates, the intervention included booklets of guideline compilations, one Android phone for digitizing images of templates, and one data feedback/continuing medical education session per clinic each month. In this paper we focus on the effect of the intervention on documentation of three non-communicable diseases in one clinic. METHODS: Seventy charts of patients enrolled in the chronic disease program (hypertension/diabetes, n=867; chronic respiratory diseases, n=223) at one of the ten intervention clinics were sampled. Documentation of each individual patient encounter in the pre-intervention (January-March 2016) and post-intervention period (May-July) was scored for information in four dimensions - general data, patient assessment, testing, and management. Control criteria included information with no counterparts in templates (e.g. notes on presenting complaints, vital signs). Documentation scores for each patient were compared between both pre- and post-intervention periods and between encounters documented with and without templates (post-intervention only). RESULTS: The total number of patient encounters in the pre-intervention (282) and post-intervention periods (264) did not differ. Mean documentation scores increased significantly in the post-intervention period on average by 21%, 24% and 17% for hypertension, diabetes and chronic respiratory diseases, respectively. Differences were greater (47%, 43% and 27%, respectively) when documentation with and without templates was compared. Changes between pre- vs.post-intervention, and with vs.without template, varied between individual dimensions of documentation. Overall, documentation improved more for general data and patient assessment than in testing or management. CONCLUSION: The use of templates improves paper-based documentation of patient care, a first step towards improving the quality of care. Rubber stamps provide a simple and low-cost method to print templates on demand. In combination with ubiquitously available mobile phones, information entered on paper can be easily and rapidly digitized. This 'frugal innovation' in m-Health can empower small, private sector facilities, where large numbers of urban patients seek healthcare, to generate digital data on routine outpatient care. These data can form the basis for evidence-based quality improvement efforts at large scale, and help deliver on the SDG promise of quality essential healthcare services for all.