Quality of care: measuring a neglected driver of improved health.

The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. We propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalize civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.

La qualité des soins dispensés par les systèmes de santé contribue aux efforts qui visent à atteindre l'objectif de développement durable n°3 sur la santé et le bien-être. De plus en plus d'éléments indiquent que l'impact des interventions dans le domaine de la santé est compromis par une mauvaise qualité des soins dans les pays aux revenus les plus faibles. La qualité des soins sera également cruciale pour la réussite des initiatives en faveur de la couverture sanitaire universelle; il est peu probable que des personnes insatisfaites de la qualité et de l'étendue des services proposés soient favorables au financement public des soins. De plus, l'éthique veut que toutes les personnes, même les plus pauvres, puissent bénéficier d'une prise en charge de qualité minimum qui leur permette de voir leur santé s'améliorer. Or, aujourd'hui, dans les pays à revenu faible et intermédiaire, l'évaluation de la qualité n'est pas à la hauteur de la tâche. Les systèmes d'information sanitaire fournissent des données incomplètes et souvent peu fiables. Quant aux enquêtes menées dans les établissements, elles recueillent trop d'indicateurs à l'utilité discutable, s'intéressent à un nombre limité de services et sont rapidement obsolètes. Les évaluations existantes n'intègrent pas bien le processus de soins et le vécu des patients. Le point de vue des patients sensibles aux pratiques de soins, un élément de base de l'évaluation de la qualité dans les pays à revenu élevé, est rarement recueilli. Nous proposons six recommandations stratégiques afin d'améliorer l'évaluation de la qualité des soins et d'amplifier son impact stratégique: (i) redoubler les efforts pour améliorer et institutionnaliser les systèmes d'enregistrement et de statistiques de l'état civil; (ii) réformer les enquêtes menées dans les établissements et renforcer les systèmes d'information courants; (iii) définir de nouvelles mesures de la qualité pour les régions aux faibles ressources; (iv) recueillir l'avis des patients concernant la qualité; (v) investir dans des données nationales de qualité; et (vi) traduire les données sur la qualité en actions ayant un impact stratégique.

La calidad de la atención proporcionada por los sistemas sanitarios contribuye a los esfuerzos para alcanzar el objetivo 3 de desarrollo sostenible en salud y bienestar. Cada vez existen más pruebas de que el impacto de las intervenciones sanitarias se ve desvirtuado por la mala calidad de la atención en países con ingresos bajos. La calidad de la salud también será fundamental para el éxito de las iniciativas de cobertura sanitaria universal; los ciudadanos que no están satisfechos con la calidad y el alcance de los servicios cubiertos no suelen apoyar la financiación pública de la atención sanitaria. Asimismo, existe un ímpetu ético para garantizar que todo el mundo, incluida la población más pobre, obtiene un estándar mínimo de calidad de atención que sea eficaz a la hora de mejorar la salud. No obstante, actualmente la medición de la calidad en países de ingresos bajos y medios no es adecuada para la tarea. Los sistemas de información sanitaria ofrecen información incompleta y a menudo poco fiable, y las encuestas en los centros recopilan demasiados indicadores de servicios públicos inestables, se centran en un número limitado de servicios y quedan obsoletos con mucha rapidez. Las medidas existentes apenas captan el proceso de atención y la experiencia del paciente. Los resultados de los pacientes sensibles a las prácticas de atención sanitaria son un elemento fundamental de la evaluación de la calidad en países con ingresos altos, y apenas se recopilan. Se proponen seis recomendaciones normativas para mejorar la medición de la calidad de la atención y ampliar el impacto de su política: (i) redoblar los esfuerzos para mejorar e institucionalizar los sistemas de registro civil y de estadísticas vitales; (ii) reformar las encuestas de los centros y fortalecer los sistemas de información rutinaria; (iii) crear nuevas medidas de calidad para contextos de pocos recursos; (iv) ofrecer al paciente una perspectiva sobre calidad; (v) invertir en datos de calidad nacionales; y (vi) traducir las pruebas de calidad para lograr un impacto de la política.

Innovative financing for health: what is truly innovative?

Development assistance for health has increased every year between 2000 and 2010, particularly for HIV/AIDS, tuberculosis, and malaria, to reach US$26·66 billion in 2010. The continued global economic crisis means that increased external financing from traditional donors is unlikely in the near term. Hence, new funding has to be sought from innovative financing sources to sustain the gains made in global health, to achieve the health Millennium Development Goals, and to address the emerging burden from non-communicable diseases. We use the value chain approach to conceptualise innovative financing. With this framework, we identify three integrated innovative financing mechanisms-GAVI, Global Fund, and UNITAID-that have reached a global scale. These three financing mechanisms have innovated along each step of the innovative finance value chain-namely resource mobilisation, pooling, channelling, resource allocation, and implementation-and integrated these steps to channel large amounts of funding rapidly to low-income and middle-income countries to address HIV/AIDS, malaria, tuberculosis, and vaccine-preventable diseases. However, resources mobilised from international innovative financing sources are relatively modest compared with donor assistance from traditional sources. Instead, the real innovation has been establishment of new organisational forms as integrated financing mechanisms that link elements of the financing value chain to more effectively and efficiently mobilise, pool, allocate, and channel financial resources to low-income and middle-income countries and to create incentives to improve implementation and performance of national programmes. These mechanisms provide platforms for health funding in the future, especially as efforts to grow innovative financing have faltered. The lessons learnt from these mechanisms can be used to develop and expand innovative financing from international sources to address health needs in low-income and middle-income countries.

Investing in improved performance of national tuberculosis programs reduces the tuberculosis burden: analysis of 22 high-burden countries, 2002-2009.

OBJECTIVE: To assess the impact of investment in national tuberculosis programs (NTPs) on NTP performance and tuberculosis burden in 22 high-burden countries, as determined by the World Health Organization (WHO). DATA SOURCE/STUDY SETTING: Estimates of annual tuberculosis burden and NTP performance indicators and control variables during 2002-2009 were obtained from the Organization for Economic Cooperation and Development, the WHO, the World Bank, and the Penn World Table for the 22 high-burden countries. STUDY DESIGN: Panel data analysis was performed using the outcome variables tuberculosis incidence, prevalence, and mortality and the key explanatory variables Partnership case detection rate and treatment success rate, controlling for gross domestic product per capita, population structure, and human immunodeficiency virus (HIV) prevalence. RESULTS: A $1 per capita (general population) higher NTP budget (including domestic and external sources) was associated with a 1.9% (95% confidence interval, .12%-3.6%) higher estimated case detection rate the following year for the 22 high-burden countries between 2002 and 2009. In the final models, which corrected for autocorrelation and heteroskedasticity, achieving the STOP TB Partnership case detection rate target of >70% was associated with significantly (P < .01) lower tuberculosis incidence, prevalence, and mortality the following year, even when controlling for general economic development and HIV prevalence as potential confounding variables. CONCLUSIONS: Increased investment in NTPs was significantly associated with improved performance and with a downward trend in the tuberculosis burden in the 22 high-burden countries during 2002-2009.

Associations between key intervention coverage and child mortality: an analysis of 241 sub-national regions of sub-Saharan Africa.

BACKGROUND: Reducing child mortality remains a key objective in the Sustainable Development Goals. Although remarkable progress has been made with respect to under-5 mortality over the last 25 years, little is known regarding the relative contributions of public health interventions and general improvements in socioeconomic status during this time period. METHODS: We combined all available data from the Demographic and Health Survey (DHS) to construct a longitudinal, multi-level dataset with information on subnational-level key intervention coverage, household socioeconomic status and child health outcomes in sub-Saharan Africa. The dataset covers 562 896 child records and 769 region-year observations across 24 countries. We used multi-level multivariable logistics regression models to assess the associations between child mortality and changes in the coverage of 17 key reproductive, maternal, newborn and child health interventions such as bednets, water and sanitation infrastructure, vaccination and breastfeeding practices, as well as concurrent improvements in social and economic development. RESULTS: Full vaccination coverage was associated with a 30% decrease in the odds of child mortality [odds ratio (OR) 0.698, 95% confidence interval (CI) 0.564, 0.864], and continued breastfeeding was associated with a 24% decrease in the odds of child mortality (OR 0.759, 95% CI 0.642, 0.898). Our results suggest that changes in vaccination coverage, as well as increases in female education and economic development, made the largest contributions to the positive mortality trends observed. Breastfeeding was associated with child survival but accounts for little of the observed declines in mortality due to declining coverage levels during our study period. CONCLUSIONS: Our findings suggest that a large amount of progress has been made with respect to coverage levels of key health interventions. Whereas all socioeconomic variables considered appear to strongly predict health outcomes, the same was true only for very few health coverage indicators.

Inequality in total fertility rates and the proximate determinants of fertility in 21 sub-Saharan African countries.

In this paper, we examine the inequality in the dynamics of the total fertility rate within 21 sub-Saharan African countries by wealth quintiles. We also examine the associated inequality within each country in the proximate determinants of fertility-marriage, contraception, and breastfeeding. Applying Bongaarts' proximate determinants of fertility framework, for 14/21 countries we analyze, we find that those in the richest wealth quintiles have had a more rapid decline in fertility rates than those in the poorest wealth quintiles. The rapid decline for those in the richest wealth quintiles is attributable to delayed marriage and modest increases in contraceptive use. Although the poorest lag in fertility decline, postpartum abstinence and breastfeeding are the most important factors for them for fertility regulation. Further encouraging maternal health programs that focus on natural methods of fertility regulation will work in favor of the poorest in sub-Saharan Africa in moving through the demographic transition.

Inferring the economic standard of living and health from cohort height: Evidence from modern populations in developing countries.

Average adult height is a physical measure of the biological standard of living of a population. While the biological and economic standards of living of a population are very different concepts, they are linked and may empirically move together. If this is so, then cohort heights can also be used to make inferences about the economic standard of living and health of a population when other data are not available. We investigate how informative this approach is in terms of inferring income, nutrition, and mortality using data on heights from developing countries over the last 50 years for female cohorts born 1951-1992. We find no evidence that the absolute differences in adult height across countries are associated with different economic living standards. Within countries, however, faster increases in adult cohort height over time are associated with more rapid growth of GDP per capita, life expectancy, and nutritional intake. Using our instrumental variable approach, each centimeter gain in height is associated with a 6% increase in income per capita, a reduction in infant mortality of 7 per thousand (or an 1.25 year increase in life expectancy), and an increase in nutrition of 64 calories and 2 grams of protein per person per day relative to the global trend. We find that increases in cohort height can predict increases in income even for countries not used in the estimation of the relationship. This suggests our approach has predictive power out of sample for countries where we lack income and health data.

Effect of investment in malaria control on child mortality in sub-Saharan Africa in 2002-2008.

BACKGROUND: Around 8.8 million children under-five die each year, mostly due to infectious diseases, including malaria that accounts for 16% of deaths in Africa, but the impact of international financing of malaria control on under-five mortality in sub-Saharan Africa has not been examined. METHODS AND FINDINGS: We combined multiple data sources and used panel data regression analysis to study the relationship among investment, service delivery/intervention coverage, and impact on child health by observing changes in 34 sub-Saharan African countries over 2002-2008. We used Lives Saved Tool to estimate the number of lives saved from coverage increase of insecticide-treated nets (ITNs)/indoor residual spraying (IRS). As an indicator of outcome, we also used under-five mortality rate. Global Fund investments comprised more than 70% of the Official Development Assistance (ODA) for malaria control in 34 countries. Each $1 million ODA for malaria enabled distribution of 50,478 ITNs [95%CI: 37,774-63,182] in the disbursement year. 1,000 additional ITNs distributed saved 0.625 lives [95%CI: 0.369-0.881]. Cumulatively Global Fund investments that increased ITN/IRS coverage in 2002-2008 prevented an estimated 240,000 deaths. Countries with higher malaria burden received less ODA disbursement per person-at-risk compared to lower-burden countries ($3.90 vs. $7.05). Increased ITN/IRS coverage in high-burden countries led to 3,575 lives saved per 1 million children, as compared with 914 lives in lower-burden countries. Impact of ITN/IRS coverage on under-five mortality was significant among major child health interventions such as immunisation showing that 10% increase in households with ITN/IRS would reduce 1.5 [95%CI: 0.3-2.8] child deaths per 1000 live births. CONCLUSIONS: Along with other key child survival interventions, increased ITNs/IRS coverage has significantly contributed to child mortality reduction since 2002. ITN/IRS scale-up can be more efficiently prioritized to countries where malaria is a major cause of child deaths to save greater number of lives with available resources.

Health trends in Sub-Saharan Africa: conflicting evidence from infant mortality rates and adult heights.

We investigate trends in cohort infant mortality rates and adult heights in 39 developing countries since 1961. In most regions of the world improved nutrition, and reduced childhood exposure to disease, have lead to improvements in both infant mortality and adult stature. In Sub-Saharan Africa, however, despite declining infant mortality rates, adult heights have not increased. We argue that in Sub-Saharan Africa the decline in infant mortality may have been due to interventions that prevent infant deaths rather than improved nutrition and childhood morbidity. Despite declining infant mortality, Sub-Saharan Africa may not be experiencing increases in health human capital.

The height of women in Sub-Saharan Africa: the role of health, nutrition, and income in childhood.

BACKGROUND: Adult height in individuals has been linked to health and nutrition in childhood, and to health outcomes in later life. Economists have used average adult height as an indicator of the biological standard of living and as a measure of health human capital. However, it is unclear to what extent childhood health and nutrition are reflected in adult height at the population level. AIM: The study examined the proximate determinants of population adult height for countries in Sub-Saharan Africa. SUBJECTS AND METHODS: A database was created of adult female height for 24 countries in Sub-Saharan Africa for birth cohorts born between 1945 and 1985. The present study examined the effect of infant mortality rate, GDP per capita, and average protein and calorie consumption on cohort adult height. RESULTS: Most of the variation in height across countries in Sub-Saharan Africa is due to fixed effects; however, it was found that variations in cohort height over time are sensitive to changes in infant mortality rate, GDP per capita, and protein intake, both at birth and in adolescence. CONCLUSIONS: Changes in cohort adult height over time in Sub-Saharan Africa are related to changes childhood health and nutrition, although variation across countries appears to be determined mainly by unexplained fixed factors.