Standards of care and determinants of women's satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey.

BACKGROUND: Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS: Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS: Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS: Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.

Investigating rapid diagnostic testing in Kenya's health system, 2018-2020: validating non-reporting in routine data using a health facility service assessment survey.

BACKGROUND: Understanding the availability of rapid diagnostic tests (RDTs) is essential for attaining universal health care and reducing health inequalities. Although routine data helps measure RDT coverage and health access gaps, many healthcare facilities fail to report their monthly diagnostic test data to routine health systems, impacting routine data quality. This study sought to understand whether non-reporting by facilities is due to a lack of diagnostic and/or service provision capacity by triangulating routine and health service assessment survey data in Kenya. METHODS: Routine facility-level data on RDT administration were sourced from the Kenya health information system for the years 2018-2020. Data on diagnostic capacity (RDT availability) and service provision (screening, diagnosis, and treatment) were obtained from a national health facility assessment conducted in 2018. The two sources were linked and compared obtaining information on 10 RDTs from both sources. The study then assessed reporting in the routine system among facilities with (i) diagnostic capacity only, (ii) both confirmed diagnostic capacity and service provision and (iii) without diagnostic capacity. Analyses were conducted nationally, disaggregated by RDT, facility level and ownership. RESULTS: Twenty-one per cent (2821) of all facilities expected to report routine diagnostic data in Kenya were included in the triangulation. Most (86%) were primary-level facilities under public ownership (70%). Overall, survey response rates on diagnostic capacity were high (> 70%). Malaria and HIV had the highest response rate (> 96%) and the broadest coverage in diagnostic capacity across facilities (> 76%). Reporting among facilities with diagnostic capacity varied by test, with HIV and malaria having the lowest reporting rates, 58% and 52%, respectively, while the rest ranged between 69% and 85%. Among facilities with both service provision and diagnostic capacity, reporting ranged between 52% and 83% across tests. Public and secondary facilities had the highest reporting rates across all tests. A small proportion of health facilities without diagnostic capacity submitted testing reports in 2018, most of which were primary facilities. CONCLUSION: Non-reporting in routine health systems is not always due to a lack of capacity. Further analyses are required to inform other drivers of non-reporting to ensure reliable routine health data.

Assessment of diagnostic accuracy and adherence to maternal and child health guidelines as a measure of clinical competence of frontline healthcare workers in Nigeria.

Clinical competence of primary healthcare (PHC) workers is important in the delivery of maternal and child health care and services. In this cross-sectional study, we investigated the diagnostic accuracy and adherence to clinical guidelines for the management of some clinical conditions such as malaria, diarrhea, pneumonia, neonatal asphyxia and postpartum hemorrhage, as a proxy to measure the clinical competence of frontline health workers in PHCs in selected states in Nigeria. Ninety PHC facilities were randomly selected in each State and the FCT. Of the 3330 health workers, only 36.0% were able to correctly diagnose the five selected medical conditions. There was a significant difference in the diagnostic accuracy of the health workers with the doctors having highest diagnostic accuracy (65.5%) compared to other health workers (p <0.001). Adherence to the management guidelines was generally poor across all cadres of health workers and this pattern appear similar across the geopolitical regions in the country. The highest adherence to guidelines was observed among medical doctors (38.2%). The diagnostic accuracy and adherence to national guidelines for managing patients was poor among health workers, particularly, among other cadres except doctors. PHC workers in Nigeria need continuous training to enhance their clinical competence to improve quality of maternal and child health care.

Malaria case management and elimination readiness in health facilities of five districts of Madagascar in 2018.

BACKGROUND: Madagascar's Malaria National Strategic Plan 2018-2022 calls for progressive malaria elimination beginning in low-incidence districts (< 1 case/1000 population). Optimizing access to prompt diagnosis and quality treatment and improving outbreak detection and response will be critical to success. A malaria elimination readiness assessment (MERA) was performed in health facilities (HFs) of selected districts targeted for malaria elimination. METHODS: A mixed methods survey was performed in September 2018 in five districts of Madagascar. Randomly selected HFs were assessed for availability of malaria commodities and frequency of training and supervision conducted. Health providers (HPs) and community health volunteers (CHVs) were interviewed, and outpatient consultations at HFs were observed. To evaluate elimination readiness, a composite score ranging from 0 to 100 was designed from all study tools and addressed four domains: (1) resource availability, (2) case management (CM), (3) data management and use, and (4) training, supervision, and technical assistance; scores were calculated for each HF catchment area and district based on survey responses. Stakeholder interviews on malaria elimination planning were conducted at national, regional and district levels. RESULTS: A quarter of the 35 HFs surveyed had no rapid diagnostic tests (RDTs). Of 129 patients with reported or recorded fever among 300 consultations observed, HPs tested 56 (43%) for malaria. Three-quarters of the 35 HF managers reviewed data for trends. Only 68% of 41 HPs reported receiving malaria-specific training. Of 34 CHVs surveyed, 24% reported that treating fever was no longer among their responsibilities. Among treating CHVs, 13 (50%) reported having RDTs, and 11 (42%) had anti-malarials available. The average district elimination readiness score was 52 out of 100, ranging from 48 to 57 across districts. Stakeholders identified several challenges to commodity management, malaria CM, and epidemic response related to lack of training and funding disruptions. CONCLUSION: This evaluation highlighted gaps in malaria CM and elimination readiness in Madagascar to address during elimination planning. Strategies are needed that include training, commodity provision, supervision, and support for CHVs. The MERA can be repeated to assess progress in filling identified gaps and is a feasible tool that could be used to assess elimination targets in other countries.

Quality of malaria services offered in public health facilities in three provinces of Mozambique: a cross-sectional study.

BACKGROUND: Fever associated with malaria is the leading cause of health care-seeking in Mozambique, yet there is limited evidence on the quality of malaria case management. This study evaluated the quality of malaria service provision offered in public health facilities in Mozambique. METHODS: A cross-sectional assessment was conducted in April-May 2018 in three provinces of Mozambique: Maputo Province (low malaria burden), Cabo Delgado (high), and Zambézia (high). The study included all secondary and tertiary facilities and a random sample of primary facilities in each province. Data collection included exit interviews and re-examinations of 20 randomly selected outpatient service patients, interviews with up to five health care providers and the health facility director, a stockroom inventory and routine data abstraction. RESULTS: A total of 319 health care providers and 1840 patients from 117 health facilities were included. Of these, 1325 patients (72%) had suspected malaria (fever/history of fever) and 550 (30%) had febrile, confirmed malaria with the highest burden in Cabo Delgado (43%), followed by Zambézia (34%) and Maputo Province (2%). Appropriate management of malaria cases, defined as testing malaria suspects and treating confirmed cases with the correct dose of anti-malarial, was highest in Zambézia and Cabo Delgado where 52% (95% CI 42-62) and 49% (42-57) of febrile malaria cases were appropriately managed, respectively. Only 14% (5-34) of febrile cases in Maputo Province were appropriately managed. The biggest gap in the malaria case management pathway was failure to test febrile patients, with only 46% of patients with this indication tested for malaria in Maputo Province. Additionally, anti-malarial treatment of patients with a negative malaria test result was common, ranging from 8% (2-23) in Maputo Province to 22% (14-32) of patients with a negative test in Zambézia. Only 58-62% of patients prescribed an anti-malarial correctly recited dosing instructions. Provider training and malaria knowledge was low outside of Zambézia and supervision rates were low in all provinces. Factors associated with correct case management varied by province and included patient age, facility type, treatment and testing availability, supervision, and training. CONCLUSION: These findings underscore the need to strengthen provider testing of all patients with fever, provider adherence to negative test results, and effective counselling of patients across epidemiological settings in Mozambique.

Quality of care for non-communicable diseases in the Republic of Moldova: a survey across primary health care facilities and pharmacies.

BACKGROUND: The Republic of Moldova is faced with a high prevalence of non-communicable diseases (NCDs) related to lifestyle and health behavioural factors. Within the frame of the decentralisation reform, the primary health care system has been tasked to play an important role in the provision of preventative and curative NCD health services. There is however limited evidence available on the actual coverage and quality of care provided. Our paper aims to provide an updated overview of the coverage and quality of service provision in rural and urban regions of Moldova. METHODS: We designed a facility-based survey to measure aspects of coverage and quality of care of NCD services across 20 districts of the Republic of Moldova. This study presents descriptive data on the structural, procedural and clinical aspects of primary healthcare delivery at health centre and family doctor office level. Adjacent private pharmacies were also assessed for the availability of essential NCD medicine. RESULTS: Organised under the WHO Health Systems Framework, our findings highlight that service provision and information were generally the strongest among the six health systems building blocks, with more weaknesses found in the area of the health workforce, medical products, financing, and leadership/governance. Urban facilities generally fared better across all indicators. CONCLUSIONS: The gaps in service provision identified by this study require broad health system improvements to ensure NCD related policies and strategies are embedded in primary health care service provision. This likely calls for stronger coordination and collaboration between the public and private sectors and the different levels of government working towards ensuring universal health coverage in Moldova.

From policy to practice: exploring the implementation of antiretroviral therapy access and retention policies between 2013 and 2016 in six sub-Saharan African countries.

BACKGROUND: Understanding the implementation of 2013 World Health Organization (WHO) consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection at the facility level provides important lessons for the roll-out of future HIV policies. METHODS: A national policy review was conducted in six sub-Saharan African countries to map the inclusion of the 2013 WHO HIV treatment recommendations. Twenty indicators of policy adoption were selected to measure ART access (n = 12) and retention (n = 8). Two sequential cross-sectional surveys were conducted in facilities between 2013/2015 (round 1) and 2015/2016 (round 2) from ten health and demographic surveillance sites in Kenya, Malawi, South Africa, Tanzania, Uganda and Zimbabwe. Using standardised questionnaires, facility managers were interviewed. Descriptive analyses were used to assess the change in the proportion of facilities that implemented these policy indicators between rounds. RESULTS: Although, expansion of ART access was explicitly stated in all countries' policies, most lacked policies that enhanced retention. Overall, 145 facilities were included in both rounds. The proportion of facilities that initiated ART at CD4 counts of 500 or less cells/µL increased between round 1 and 2 from 12 to 68%, and facilities initiating patients on 2013 WHO recommended ART regimen increased from 42 to 87%. There were no changes in the proportion of facilities reporting stock-outs of first-line ART in the past year (18 to 11%) nor in the provision of three-month supply of ART (43 to 38%). None of the facilities provided community-based ART delivery. CONCLUSION: The increase in ART initiation CD4 threshold in most countries, and substantial improvements made in the provision of WHO recommended first-line ART regimens demonstrates that rapid adoption of WHO recommendations is possible. However, improved logistics and resources and/or changes in policy are required to further minimise ART stock-outs and allow lay cadres to dispense ART in the community. Increased efforts are needed to offer longer durations between clinic visits, a strategy purported to improve retention. These changes will be important as countries move to implement the revised 2015 WHO guidelines to initiate all HIV positive people onto ART regardless of their immune status.

Provision and utilization of maternal health services during the COVID-19 pandemic in 16 hospitals in sub-Saharan Africa.

Objective: Maintaining provision and utilization of maternal healthcare services is susceptible to external influences. This study describes how maternity care was provided during the COVID-19 pandemic and assesses patterns of service utilization and perinatal health outcomes in 16 referral hospitals (four each) in Benin, Malawi, Tanzania and Uganda. Methods: We used an embedded case-study design and two data sources. Responses to open-ended questions in a health-facility assessment survey were analyzed with content analysis. We described categories of adaptations and care provision modalities during the pandemic at the hospital and maternity ward levels. Aggregate monthly service statistics on antenatal care, delivery, caesarean section, maternal deaths, and stillbirths covering 24 months (2019 and 2020; pre-COVID-19 and COVID-19) were examined. Results: Declines in the number of antenatal care consultations were documented in Tanzania, Malawi, and Uganda in 2020 compared to 2019. Deliveries declined in 2020 compared to 2019 in Tanzania and Uganda. Caesarean section rates decreased in Benin and increased in Tanzania in 2020 compared to 2019. Increases in maternal mortality ratio and stillbirth rate were noted in some months of 2020 in Benin and Uganda, with variability noted between hospitals. At the hospital level, teams were assigned to respond to the COVID-19 pandemic, routine meetings were cancelled, and maternal death reviews and quality improvement initiatives were interrupted. In maternity wards, staff shortages were reported during lockdowns in Uganda. Clinical guidelines and protocols were not updated formally; the number of allowed companions and visitors was reduced. Conclusion: Varying approaches within and between countries demonstrate the importance of a contextualized response to the COVID-19 pandemic. Maternal care utilization and the ability to provide quality care fluctuated with lockdowns and travel bans. Women's and maternal health workers' needs should be prioritized to avoid interruptions in the continuum of care and prevent the deterioration of perinatal health outcomes.

Disparities in readiness of health facilities to provide long-acting reversible contraceptives (LARCs) and permanent methods (PMs) in Bangladesh.

The considerable success of Bangladesh's family planning programs Slowed in recent years due to the low utilization of long-acting reversible contraceptives (LARCs) and permanent methods (PMs). The low uptake persists despite the fact that these methods are proven to be highly effective in preventing unplanned pregnancies and lowering maternal deaths. This situation causes a daunting challenge for the country to attain sustainable development goals (SDGs) by 2030. The current study provides new insights into the status of LARCs and PMs availability in Bangladesh from the supply-side perspective. The main objective of this study was to assess the readiness of health facilities to provide all LARCs and all PMs in Bangladesh. To assess service readiness, we examined variations in facility types and regions, using data from the Bangladesh Health facility Survey (BHFS) 2017. Out of a total of 1054 health facilities assessed, government health facilities manifested higher availability of items of general service readiness for LARCs and PMs compared to private health facilities. Service readiness included domains including staff and guidelines, equipment, and medicine. Logistic regression models of readiness of LARCs, PMs, and combined LARCs-PMs showed significant variations by facility types and regions. Moreover, the findings of this study highlighted that, Bangladesh government facilities, irrespective of region, were more likely to be ready to provide combined LARCs-PMs, LARCs, and PMs individually than private health facilities. Looking more closely at the overall readiness within private health facilities, we found that it was better in rural areas than in urban areas. The findings of this study provide a basis to develop recommend strategic approaches to family planning programs, investment priorities in family planning services and, training for service providers to reduce regional inequality and disparities by facility types in Bangladesh.

Parental satisfaction with health care during child hospitalization at a social security facility in Mexico.

BACKGROUND: The Service Quality in Hospital (SERVQHOS) assesses quality and satisfaction with hospital care received. This study aimed to determine the quality and satisfaction of parents in a tertiary-level pediatric public facility in Mexico. METHODS: We conducted a cross-sectional study in which 425 anonymous surveys were distributed during the discharge of children. The questionnaire evaluates the individual (subjective) and organizational (objective) quality of service: reliability, tangibles, assurance, responsiveness, and empathy, as well as satisfaction on a 5-point scale from 1 (much worse) to 5 (much better). RESULTS: A total of 401 questionnaires were returned (94%). The mean quality score was 3.6 ± 0.7. The best-rated aspects were the medical equipment technology (3.6 + 0.8), the confidence that the staff transmits to patients (3.6 ± 0.8), and the friendliness of the staff when attending patients (3.6 ± 0.8). The worst-rated aspects were the condition of the rooms (3.4 ± 0.8), the waiting time to be attended by a physician (3.3 ± 0.8), and the timeliness of internal consultations (3.3 ± 0.8). The overall population rated as satisfied in 97% of cases. CONCLUSIONS: A high rate of satisfaction was observed concerning both objective and subjective factors. However, the negative aspects of objective quality, such as reliability, should be addressed organizationally without implying economic investment in their resolution.

INTRODUCCIÓN: La prueba de Calidad en el Servicio de Hospital (SERVQHOS) evalúa la calidad y la satisfacción con la atención hospitalaria recibida. El objetivo de este estudio fue determinar la calidad y la satisfacción de los padres de familia en un hospital público pediátrico de tercer nivel en México. MÉTODOS: Se realizó un estudio transversal en el que se distribuyeron 425 encuestas anónimas durante el alta de los pacientes. El cuestionario evalúa la calidad individual (subjetiva) y de la organización (objetiva) del servicio: fiabilidad, tangibles, garantía, capacidad de respuesta y empatía, y satisfacción en una escala tipo Likert de 5 puntos, de 1 (mucho peor) a 5 (mucho mejor). RESULTADOS: Se recibieron 401 encuestas respondidas (tasa de respuesta del 94%). El 97% de los padres calificaron la satisfacción global como satisfechos o muy satisfechos. Los aspectos mejor calificados fueron la tecnología de los equipos médicos (3.6 ± 0.8), la confianza que el personal transmite al paciente (3.6 ± 0.8) y la amabilidad del personal en su trato al paciente (3.6 ± 0.8). Los aspectos peor valorados fueron el estado de las habitaciones (3.4 ± 0.8), el tiempo de espera para ser atendido por un médico (3.3 ± 0.8) y la puntualidad de las interconsultas (3.3 ± 0.8). CONCLUSIONES: Se observó un alto índice de satisfacción relacionado tanto con los factores objetivos como con los subjetivos. Sin embargo, los aspectos negativos de calidad objetiva, tales como la fiabilidad, deben ser atendidos por la organización sin que ello implique una inversión económica para su resolución.

The effect of power outages on in-facility mortality in healthcare facilities: Evidence from Ghana.

The World Bank estimates that at least 25 countries in the Sub-Saharan region of Africa experience chronic power outages. However, the implications of power shortages are often discussed within the context of industrial and economic disruptions, with little attention given to the health impact. Using a nationally representative data of healthcare facilities from the 2012 Ghana Access, Bottlenecks, Cost and Equity (ABCE) Health Facility Survey, this study aims to assess the impact of power outages on in-healthcare facility mortality in Ghana, a country that has experienced worsening energy crises in the last few decades. Findings revealed a positive association between the frequency of power outages and in-facility mortality, with the risk for mortality estimated to increase by 43% for each day the power was out for over 2 h. Further, when compared to an urban healthcare facility experiencing the same frequency of power outages, the risk of mortality was found to be lower in the rural facility. These findings call for a concerted effort among all stakeholders to ensure the availability of consistent power supply in healthcare facilities, in order to provide the necessary environment for the successful provision of healthcare for the citizens of Ghana.

Improving and sustaining quality of child health care through IMCI training and supervision: experience from rural Bangladesh.

BACKGROUND: The Integrated Management of Childhood Illness (IMCI) strategy includes guidelines for the management of sick children at first-level facilities. These guidelines intend to improve quality of care by ensuring a complete assessment of the child's health and by providing algorithms that combine presenting symptoms into a set of illness classifications for management by IMCI-trained service providers at first-level facilities. OBJECTIVES: To investigate the sustainability of improvements in under-five case management by two cadres of first-level government service providers with different levels of pre-service training following implementation of IMCI training and supportive supervision. METHODS: Twenty first-level health facilities in the rural sub-district of Matlab in Bangladesh were randomly assigned to IMCI intervention or comparison groups. Health workers in IMCI facilities received training in case management and monthly supportive supervision that involved observations of case management and reinforcement of skills by trained physicians. Health workers in comparison facilities were supervised according to Government of Bangladesh standards. Health facility surveys involving observations of case management were carried out at baseline (2000) and at two points (2003 and 2005) after implementation of IMCI in intervention facilities. FINDINGS: Improvement in the management of sick under-five children by IMCI trained service providers with only 18 months of pre-service training was equivalent to that of service providers with 4 years of pre-service training. The improvements in quality of care were sustained over a 2-year period across both cadres of providers in intervention facilities. CONCLUSION: IMCI training coupled with regular supervision can sustain improvements in the quality of child health care in first-level health facilities, even among workers with minimal pre-service training. These findings can guide government policy makers and provide further evidence to support the scale-up of regular supervision and task shifting the management of sick under-five children to lower-level service providers.