Abstract
ObjectiveTo analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries.MethodsWe pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006–2014). Based on World Health Organization protocols, we created indices of process quality for antenatal care (first visits) and for sick-child visits. We assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service.FindingsData were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% (interquartile range, IQR: 50.0 to 75.0) of eight recommended antenatal care actions and 54.5% (IQR: 33.3 to 66.7) of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined.ConclusionThe quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.
Highlights
Substantial progress has been made in reducing child and maternal deaths in the past 15 years, many women and children in low- and middle-income countries continue to die of avertable causes.[1]
We focused on sub-Saharan Africa and included all surveys between 2006 and 2014 that had data on observations of antenatal and sick-child care (Kenya, 2010; Malawi, 2013; Namibia, 2009; Rwanda, 2007; Senegal, 2012–2014; Uganda, 2007; the United Republic of Tanzania, 2006; Table 1)
Observers, who were specially trained researchers, assessed: (i) first visits or follow-up visits for antenatal care; and (ii) consultations for children aged five years or younger presenting with illness
Summary
Substantial progress has been made in reducing child and maternal deaths in the past 15 years, many women and children in low- and middle-income countries continue to die of avertable causes.[1]. These data have informed programmes to promote utilization of health care, by providing information, insurance schemes and utilization incentives for communities, among other means.[8,9,10]
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