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

OBJECTIVES: Recent studies have identified large and systematic deficits in clinical care in low-income countries that are likely to limit health gains. This has focused attention on effectiveness of pre-service education. One approach to assessing this is observation of clinical performance among recent graduates providing care. However, no studies have assessed performance in a standard manner across countries. We analysed clinical performance among recently graduated providers in nine low- or middle-income countries. METHODS: Service Provision Assessments from Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda were used. We constructed a Good Medical Practice Index that assesses completion of essential clinical actions using direct observations of care (range 0-1), calculated index scores by country and clinical cadre, and assessed the role of facility and clinical characteristics using regression analysis. RESULTS: Our sample consisted of 2223 clinicians with at least one observation of care. The Good Medical Practice score for the sample was 0.50 (SD = 0.20). Nurses and midwives had the highest score at 0.57 (SD = 0.20), followed by associate clinicians at 0.43 (SD = 0.18), and physicians at 0.42 (SD = 0.16). The average national performance varied from 0.63 (SD = 0.18) in Uganda to 0.39 (SD = 0.17) in Nepal, persisting after adjustment for facility and clinician characteristics. CONCLUSIONS: These results show substantial gaps in clinical performance among recently graduated clinicians, raising concerns about models of clinical education. Competency-based education should be considered to improve quality of care in LMICs. Observations of care offer important insight into the quality of clinical education.

OBJECTIFS: Des études récentes ont identifié des déficits importants et systématiques dans les soins cliniques dans les pays à faible revenu, susceptibles de limiter les progrès en matière de santé. Cela a attiré l'attention sur l'efficacité de la formation initiale. Une des approches permettant cette évaluation a été l'observation de la performance clinique des diplômés récents dispensant des soins. Cependant, aucune étude n'a évalué la performance de manière standard dans tous les pays. Nous avons analysé les performances cliniques de prestataires récemment diplômés dans neuf pays à revenu faible ou intermédiaire. MÉTHODES: Des évaluations de la fourniture de services en Haïti, au Kenya, au Malawi, en Namibie, au Népal, au Rwanda, au Sénégal, en Tanzanie et en Ouganda ont été utilisées. Nous avons construit un indice de bonne pratique médicale qui évalue l'achèvement des actions cliniques essentielles à l'aide d'observations directes des soins (plage de 0 à 1), calculé les scores d'index par pays et par cadre clinique, et évalué le rôle de l'établissement et des caractéristiques cliniques à l'aide d'une analyse de régression. RÉSULTATS: Notre échantillon était constitué de 2.223 cliniciens avec au moins une observation des soins. Le score de bonne pratique médicale pour l'échantillon était de 0,50 (écart-type = 0,20). Les infirmières et les sages-femmes avaient le score le plus élevé de 0,57 (écart-type = 0,20), suivies des cliniciens associés avec 0,43 (écart-type = 0,18) et des médecins avec 0,42 (écart-type = 0,16). La performance moyenne nationale variait de 0,63 (écart-type = 0,18) en Ouganda à 0,39 (écart-type = 0,17) au Népal, persistant après ajustement en fonction des caractéristiques de l'établissement et du clinicien. CONCLUSIONS: Ces résultats montrent des écarts substantiels dans les performances cliniques des cliniciens récemment diplômés, ce qui soulève des inquiétudes concernant les modèles de formation clinique. Une éducation axée sur les compétences devrait être envisagée pour améliorer la qualité des soins dans les PRFM. Les observations des soins offrent des informations importantes sur la qualité de la formation clinique.

Redesigning primary care to tackle the global epidemic of noncommunicable disease.

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

Population preferences for health care in liberia: insights for rebuilding a health system.

OBJECTIVE. To quantify the influence of health system attributes, particularly quality of care, on preferences for health clinics in Liberia, a country with a high burden of disease that is rebuilding its health system after 14 years of civil war. DATA SOURCES/STUDY SETTING. Informed by focus group discussions, a discrete choice experiment (DCE) was designed to assess preferences for structure and process of care at health clinics. The DCE was fielded in rural, northern Liberia as part of a 2008 population-based survey on health care utilization. DATA COLLECTION. The survey response rate was 98 percent with DCE data available for 1,431 respondents. Mixed logit models were used to estimate the influence of six attributes on choice of hypothetical clinics for a future illness. PRINCIPAL FINDINGS. Participants' choice of clinic was most influenced by provision of a thorough physical exam and consistent availability of medicines. Respectful treatment and government (versus NGO) management marginally increased utility, whereas waiting time was not significant. CONCLUSIONS. Liberians value technical quality of care over convenience, courtesy, and public management in selecting clinics for curative care. This suggests that investments in improved competence of providers and availability of medicines may increase population utilization of essential services as well as promote better clinical outcomes.

Which doctor?: Determinants of utilization of formal and informal health care in postconflict liberia.

BACKGROUND: Liberia is rebuilding its health system after a lengthy civil war in which traditional health care was the only reliable source of care. OBJECTIVE: This study explored individual, village, and health system factors related to the utilization of health clinics versus informal providers (eg, healers, medicine sellers) in Liberia. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES: This was a cross-sectional population-representative survey of 1435 adults living in rural Nimba County, Liberia. Participants were asked about past year visits to traditional and formal health care providers and demographics, health, and trauma indicators. The association between formal and informal visits and potential determinants was estimated in separate models using generalized estimating equations to adjust for village-level clustering. RESULTS: The median number of visits in the past year to formal and informal providers was 3 and 10, respectively. Clinic visits increased with younger age and female sex, past trauma exposure, the number of traditional healers, and the presence of a facility dispenser. Frequency of informal visits increased with poor self-reported mental and physical health, the presence of facility fees and decreased with literacy and wealth and satisfaction with the formal health system. CONCLUSIONS: Rural Liberians use both formal and informal health care extensively and as complements rather than substitutes. The reliance on traditional medicine to address health needs is of concern in a country with a high disease burden. Health system investments that build public confidence in the health system may help shift demand from informal to formal health care.

Dissatisfaction with traditional birth attendants in rural Tanzania.

OBJECTIVE: To assess women's satisfaction with traditional birth attendants (TBAs) in rural Tanzania. METHOD: A population-representative sample of households in Kasulu district was used to collect data on demographics, childbirth history, and perception of TBAs and doctors/nurses from women who had recently had a child and from their partners. RESULTS: Two-thirds of women who gave birth in a health facility reported being very satisfied with the experience, compared with 21.2% of women who delivered at home with TBAs. A sizeable proportion of women felt that TBAs had poor medical skills (23.1%), while only 0.3% of women felt the same about doctors' and nurses' skills. Of women who delivered with a TBA, 16.0% reported that TBAs had poor medical skills whereas 0.5% stated the same for doctors and nurses. CONCLUSION: Although many women delivered at home in this rural study district, women and their partners reported higher confidence in doctors and nurses than in TBAs. Policymakers and program managers should not assume that women prefer TBAs to trained professionals for delivery but should consider system barriers to facility delivery in interventions aimed at reducing maternal mortality.

Equity of skilled birth attendant utilization in developing countries: financing and policy determinants.

OBJECTIVES: Developing countries with higher health care spending have greater overall utilization of maternal health services than do countries with lower spending. However, the rich tend to disproportionately use these services. We assessed whether redistributive government policies in the context of higher levels of health spending were associated with more-equitable use of skilled birth attendants (doctors, nurses, or midwives) between rich and poor. METHODS: We used data from Demographic and Health Surveys of 45 developing countries and disaggregated by wealth quintile. Multivariable regression analyses were used to assess the joint effect of higher health care expenditures, the wealth distribution of women's fifth-grade education (a proxy for redistributive policy environment within the central government) and the overall proportion of women with fifth-grade education (a proxy for female literacy and an indicator of governments' commitment to girls' education). RESULTS: We found that utilization of skilled birth attendants was more equitable when higher health expenditures were accompanied by redistributive education policies. CONCLUSIONS: Higher health care expenditures should be accompanied by redistributive policies to reduce the gap in utilization of skilled birth attendants between poorer and richer women in developing countries.