Quality of antenatal care and client satisfaction in Kenya and Namibia.

OBJECTIVE: Despite much progress in maternal health service coverage, the quality of care has not seen parallel improvement. This study assessed the quality of antenatal care (ANC), an entry point to the health system for many women. DESIGN: The study used data from recent Service Provision Assessment (SPA) surveys of nationally representative health facilities in Kenya and Namibia. SETTING: Kenya and Namibia represent the situation in much of sub-Saharan Africa, where ANC is relatively common but maternal mortality remains high. PARTICIPANTS: The SPA comprised an inventory of health facilities that provided ANC, interviews with ANC providers and clients, and observations of service delivery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Quality was measured in terms of structure and process of service provision, and client satisfaction as the outcome of service provision. RESULTS: Wide variations in structural and process attributes of quality of care existed in both Kenya and Namibia; however, better structural quality did not translate to better service delivery process or greater client satisfaction. Long waiting time was a common problem and was generally more serious in hospitals and health centers than in clinics and smaller facilities; it was consistently associated with lower client satisfaction. The study also indicates that the provider's technical preparedness may not be sufficient to provide good-quality services and to ensure client satisfaction. CONCLUSIONS: Findings highlight important program implications, including improving ANC services and promoting their use at health clinics and lower-level facilities, and ensuring that available supplies and equipment are used for service provision.

Comparison of medicine availability measurements at health facilities: evidence from Service Provision Assessment surveys in five sub-Saharan African countries.

BACKGROUND: With growing emphasis on health systems strengthening in global health, various health facility assessment methods have been used increasingly to measure medicine and commodity availability. However, few studies have systematically compared estimates of availability based on different definitions. The objective of this study was to compare estimates of medicine availability based on different definitions. METHODS: A secondary data analysis was conducted using data from the Service Provision Assessment (SPA)--a nationally representative sample survey of health facilities--conducted in five countries: Kenya SPA 2010, Namibia SPA 2009, Rwanda SPA 2007, Tanzania SPA 2006, and Uganda SPA 2007. For 32 medicines, percent of facilities having the medicine were estimated using five definitions: four for current availability and one for six-month period availability. 'Observed availability of at least one valid unit' was used as a reference definition, and ratios between the reference and each of the other four estimates were calculated. Summary statistics of the ratios among the 32 medicines were calculated by country. The ratios were compared further between public and non-public facilities within each country. RESULTS: Across five countries, compared to current observed availability of at least one valid unit, 'reported availability without observation' was on average 6% higher (ranging from 3% in Rwanda to 8% in Namibia), 'observed availability where all units were valid' was 11% lower (ranging from 2% in Tanzania to 19% in Uganda), and 'six-month period availability' was 14% lower (ranging from 5% in Namibia to 25% in Uganda). CONCLUSIONS: Medicine availability estimates vary substantially across definitions, and need to be interpreted with careful consideration of the methods used.