Quality of routine health data at the onset of the COVID-19 pandemic in Ethiopia, Haiti, Laos, Nepal, and South Africa.

BACKGROUND: During the COVID-19 pandemic, governments and researchers have used routine health data to estimate potential declines in the delivery and uptake of essential health services. This research relies on the data being high quality and, crucially, on the data quality not changing because of the pandemic. In this paper, we investigated those assumptions and assessed data quality before and during COVID-19. METHODS: We obtained routine health data from the DHIS2 platforms in Ethiopia, Haiti, Lao People's Democratic Republic, Nepal, and South Africa (KwaZulu-Natal province) for a range of 40 indicators on essential health services and institutional deaths. We extracted data over 24 months (January 2019-December 2020) including pre-pandemic data and the first 9 months of the pandemic. We assessed four dimensions of data quality: reporting completeness, presence of outliers, internal consistency, and external consistency. RESULTS: We found high reporting completeness across countries and services and few declines in reporting at the onset of the pandemic. Positive outliers represented fewer than 1% of facility-month observations across services. Assessment of internal consistency across vaccine indicators found similar reporting of vaccines in all countries. Comparing cesarean section rates in the HMIS to those from population-representative surveys, we found high external consistency in all countries analyzed. CONCLUSIONS: While efforts remain to improve the quality of these data, our results show that several indicators in the HMIS can be reliably used to monitor service provision over time in these five countries.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

Comparing absolute and relative distance and time travel measures of geographic access to healthcare facilities in rural Haiti.

INTRODUCTION: While travel distance and time are important proxies of physical access to health facilities, obtaining valid measures with an appropriate modelling method remains challenging in many settings. We compared five measures of geographic accessibility in Haiti, producing recommendations that consider available analytic resources and geospatial goals. METHODS: Eight public hospitals within the ministry of public health and population were included. We estimated distance and time between hospitals and geographic centroids of Haiti's section communes and population-level accessibility. Geographic feature data were obtained from public administrative databases, academic research databases and government satellites. We used validated geographic information system methods to produce five geographic access measures: (1) Euclidean distance (ED), (2) network distance (ND), (3) network travel time (NTT), (4) AccessMod 5 (AM5) distance (AM5D) and (5) AM5 travel time (AM5TT). Relative ranking of section communes across the measures was assessed using Pearson correlation coefficients, while mean differences were assessed using analysis of variance (ANOVA) and pairwise t-tests. RESULTS: All five geographic access measures were highly correlated (range: 0.78-0.99). Of the distance measures, ED values were consistently the shortest, followed by AM5D values, while ND values were the longest. ND values were as high as 2.3 times ED values. NTT models generally produced longer travel time estimates compared with AM5TT models. ED consistently overestimated population coverage within a given threshold compared with ND and AM5D. For example, population-level accessibility within 15 km of the nearest studied hospital in the Center department was estimated at 68% for ED, 50% for AM5D and 34% for ND. CONCLUSION: While the access measures were highly correlated, there were significant differences in the absolute measures. Consideration of the benefits and limitations of each geospatial measure together with the intended purpose of the estimates, such as relative proximity of patients or service coverage, are key to guiding appropriate use.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Hospital-provision of essential primary care in 56 countries: determinants and quality.

OBJECTIVE: To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres. METHODS: We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data. FINDINGS: On average across 56 countries, public hospitals were used as the sole source of care by 16.9% of 126 012 women who obtained contraceptives, 23.1% of 418 236 women who received routine antenatal care, 19.9% of 47 677 children with diarrhoea and 18.5% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received. CONCLUSION: As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.

Barriers and facilitators influencing facility-based childbirth in rural Haiti: a mixed method study with a convergent design.

INTRODUCTION: Haiti has the highest maternal mortality rate in the Western Hemisphere. Facility-based childbirth is promoted as the standard of care for reducing maternal and neonatal mortality. We conducted a convergent, mixed methods study to assess barriers and facilitators to facility-based childbirth at Hôpital Universitaire de Mirebalais (HUM) in Mirebalais, Haiti. METHODS: We conducted secondary analyses of a prospective cohort of pregnant women seeking antenatal care at HUM and quantitatively assessed predictors of not having a facility-based childbirth at HUM. We prospectively enrolled 30 pregnant women and interviewed them about their experiences delivering at home or at HUM. RESULTS: Of 1105 pregnant women seeking antenatal care at the hospital between May and December 2017, 773 (70%) returned to the hospital for facility-based childbirth. In multivariable analyses, living farther from the hospital (adjusted OR (AOR)=0.73; 95% CI 0.56 to 0.96), poverty (AOR=0.93; 95% CI 0.88 to 0.99) and household hunger (AOR=0.45; 95% CI 0.26 to 0.79) were associated with not having a facility-based childbirth. Primigravid women were more likely to have a facility-based childbirth (AOR=1.34, 95% CI 1.02 to 1.76). Qualitative data provided insight into the value women place on traditional birth attendants ('matrons') during home-based childbirths. While women perceived facility-based childbirths as better equipped to handle birth complications, barriers such as distance, costs of transportation and supplies, discomfort of facility birthing practices and mistreatment by medical staff resulted in negative perceptions of facility-based childbirths. CONCLUSION: Pregnant women in rural Haiti must overcome substantial structural barriers and forfeit valued support from traditional birth attendants when they pursue facility-based childbirths. If traditional birth attendants could be involved in care alongside midwives at facilities, women may be more inclined to deliver there. While complex structural barriers remain, the inclusion of matrons at facilities may increase uptake of facility-based childbirths, and ultimately improve maternal and neonatal outcomes.

Food insecurity as a risk factor for preterm birth: a prospective facility-based cohort study in rural Haiti.

INTRODUCTION: Haiti has an estimated neonatal mortality rate of 32/1000 live births, the highest in the Western Hemisphere. Preterm birth and being born small for gestational age (SGA) are major causes of adverse neonatal outcomes worldwide. To reduce preterm birth and infants born SGA, it is important to understand which women are most at risk and how risk varies within countries. There are few studies estimating the prevalence and risk factors for these conditions in Haiti, particularly in rural regions. METHODS: We conducted a prospective cohort study of pregnant women at a rural tertiary care centre in Haiti from May to December 2017. We collected data during interviews and from the medical record. We built multivariable models to identify risk factors for preterm birth and being born SGA among women who had a facility-based delivery. RESULTS: 1089 pregnant women delivered at the hospital and were included in this analysis. Median gestational age at delivery was 38 weeks (IQR 36-40). In multivariable analyses, risk factors for preterm birth included maternal age <20 years (adjusted OR (AOR) 1.76, 95% CI 1.14 to 2.72) and >34 years (AOR 1.46, 95% CI 1.01 to 2.11) and severe hunger in the household (AOR 1.57, 95% CI 1.09 to 2.26). Risk factors for SGA were age >34 years (AOR 1.76, 95% CI 1.18 to 2.59), twin pregnancy (AOR 3.28, 95% CI 1.20 to 8.95) and first pregnancy (AOR 1.57, 95% CI 1.12 to 2.23). Number of prior abortions was associated with reduced risk for SGA (AOR 0.41, 95% CI 0.17 to 0.97). CONCLUSIONS: Food insecurity as a risk factor for preterm birth stands out as an important addition to the understanding of the risk of neonatal morbidity and mortality. This association highlights a potentially important intervention target to improve birth outcomes and suggests that food support has an important role to play for pregnant women who are food insecure in low-income settings.

Postpartum quality improvement strategy for increasing long-acting contraception uptake at a University Hospital in Haiti.

To address the gap in the uptake of long-acting contraception (LAC) methods among high-risk postpartum women who fail to return for a family planning method at HôpitalUniversitaire de Mirebalais in the Central Plateau Department of Haiti, contraceptive implant trainings were held for providers on the Labour and Delivery, Post-Partum and Internal Medicine inpatient wards. A very high maternal mortality rate affects large numbers of women in Haiti; however, contraceptive use can reduce maternal mortality significantly. A quality improvement strategy to offer LAC methods to immediate postpartum women at a University Hospital in rural Haiti was initiated in March 2016. This new strategy produced an average improvement from 5% to 32% of women delivering at the hospital, accepting a long-acting method (including bilateral tubal ligations) by the end of the project and which has proved sustainable at an average of 20% to date.

Does quality influence utilization of primary health care? Evidence from Haiti.

BACKGROUND: Expanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti. METHODS: We constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery. RESULTS: Facilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure. CONCLUSIONS: Poor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.

Assessing the quality of primary care in Haiti.

OBJECTIVE: To develop a composite measure of primary care quality and apply it to Haiti's primary care system. METHODS: Using the Primary Health Care Performance Initiative's framework, we defined four domains of primary care service delivery: (i) accessible care; (ii) effective service delivery; (iii) management and organization; and (iv) primary care functions. We gave each primary care facility in Haiti a quality score for each domain and overall, with poor, fair and good quality indicated by scores of 0.00-0.49, 0.50-0.74 and 0.75-1.00, respectively. We quantified access and effective access to primary care as the proportions of the population within 5 km of any primary care facility and a good facility, respectively. FINDINGS: Of the 786 primary care facilities in Haiti in 2013, only 332 (43%) facilities were classified as good for accessible care. Fewer facilities were classified as good in the domains of effective service delivery (30; 4%), management and organization (91; 12%) and primary care functions (43; 5%). Although about 91% of the population lived within 5 km of a primary care facility, only an estimated 23% of the entire population - including just 5% of the rural population - had access to primary care of good quality. CONCLUSION: Despite an extensive network of health facilities, a minority of Haitians had access to a primary care facility of good quality. Such facilities were especially scarce in rural areas. Similar systematic analyses of the quality of primary care could inform national efforts to strengthen health systems.

Going beyond the vertical: leveraging a national HIV quality improvement programme to address other health priorities in Haiti.

Although the central role of quality to achieve targeted population health goals is widely recognized, how to spread the capacity to measure and improve quality across programmes has not been widely studied. We describe the successful leveraging of expertise and framework of a national HIV quality improvement programme to spread capacity and improve quality across a network of clinics in HIV and other targeted areas of healthcare delivery in rural Haiti.The work was led by Zamni LaSante, a Haitian nongovernment organization and its sister organization, Partners In Health working in partnership with the Haitian Ministry of Health in the Plateau Central and Lower Artibonite regions in 12 public sector facilities.Data included routinely collected organizational assessments of facility quality improvement capacity, national HIV performance measures and Zamni LaSante programme records.We found that facility quality improvement capacity increased with spread from HIV to other areas of inpatient and outpatient care, including tuberculosis (TB), maternal health and inpatient services in all 12 supported healthcare facilities. A significant increase in the quality of HIV care was also seen in most areas, including CD4 monitoring, TB screening, HIV treatment (all P < 0.01) and nutritional assessment and prevention of mother-to-child transmission (both P < .05), with an increase in average facility performance from 39 to 72% (P < .01).In conclusion, using a diagonal approach to leverage a national vertical programme for wider benefit resulted in accelerated change in professional culture and increased capacity to spread quality improvement activities across facilities and areas of healthcare delivery. This led to improvement within and beyond HIV care and contributed to the goal of quality of care for all.

Expectations, gains, and losses in the anterior cingulate cortex.

The anterior cingulate cortex (ACC) participates in evaluating actions and outcomes. Little is known on how action-reward values are processed in ACC and if the context in which actions are performed influences this processing. In the present article, we report ACC unit activity of monkeys performing two tasks. The first task tested whether the encoding of reward values is co ntext dependent-that is, dependent on the size of theother rewards that are available in the current block of trials. The second task tested whether unexpected events signaling a change in reward are represented. We show that the context created by a block design (i.e., the context of possible alternative rewards) influences the encoding of reward values, even if no decision or choice is required. ACC activity encodes the relative and not absolute expected reward values. Moreover, cingulate activitysignals and evaluates when reward expectations are violated by unexpected stimuli, indicating reward gains or losses.

Anterior cingulate error-related activity is modulated by predicted reward.

Learning abilities depend on detection and exploitation of errors. In primates, this function involves the anterior cingulate cortex. However, whether anterior cingulate error-related activity indicates occurrence of inappropriate responses or results from other computations is debated. Here we have tested whether reward-related parameters modulate error-related activity of anterior cingulate neurons. Recordings in monkeys performing stimulus-reward associations and preliminary data obtained with a problem-solving task revealed major properties of error-related unit activity: (i) their amplitude varies with the amount of predicted reward or the proximity to reward delivery; (ii) they appear both after execution and performance errors; (iii) they do not indicate which error occurred or which correction to make; and (iv), importantly, the activity of these neurons also increases following an external signal indicating the necessity to shift response. Hence, we conclude that anterior cingulate 'error' activity might represent a negative deviation from a predicted goal, and does not only reflect error detection but signals events interrupting potentially rewarded actions.

Reward anticipation, cognition, and electrodermal activity in the conditioned monkey.

In the present report, we examine electrodermal activity (skin conductance responses, SCRs) in monkeys trained to perform target-selection (TS) tests. In each test, the animal was presented in successive trials with the same two unequally rewarded targets on a touch screen. The probabilistic contingencies of the rewards associated with each target rendered the selection of the best difficult. Our findings revealed SCRs time-locked to the arm movements toward the rewarded targets, occurring after the target touches. Parameters of the SCRs were stable when the uncertainty of the choices and of the outcomes varied. The results support the hypothesis that the physiological processes indexed by the SCRs are the correlate of anticipatory appetitive behavior. In contrast, there is no evidence that the SCRs reflect cognitive processes associated with the detection of the best target.