Sample Of Health Facilities Research Articles

Technical efficiency of ghanaian health facilities before and during the COVID-19 pandemic

PurposeUnderstanding the technical efficiency of health facilities is essential for an optimal allocation of scarce resources to primary health sectors. The COVID-19 pandemic may have further undermined levels of efficiency in low-resource settings. This study takes advantage of 2019 and 2020 data on characteristics of health facilities, health services inputs and output to examine the levels and changes in efficiency of Ghanaian health facilities. The current study by using a panel dataset contributes to existing evidence, which is mostly based on pre-COVID-19 and single-period data.MethodsThe analysis is based on a panel dataset including 151 Ghanaian health facilities. Data Envelopement Analysis (DEA) technique was used to estimate the level and changes in efficiency of health facilities across two years..ResultsThe results show a net increase of 26% in inputs, influenced mostly by increases in temporary non-clinical staff (131%) and attrition of temporary clinical staff and permanent non-clinical staff, 40% and 54% respectively. There was also a net reduction in output of 34%, driven by a reduction in in-patient days (37%), immunization (11%), outpatients visits and laboratory test of 9%. Nowithstanding the COVID-19 pandemic, the results indicate that 59 (39%) of sampled health facilities in 2020 were efficient, compared to 48 (32%) in 2019. The results also indicate that smaller-sized health facilities were less likely to be efficient compared to relatively bigger health facilities.ConclusionBased on the findings, it will be essential to examine factors that accounted for efficiency improvements in some health facilities, to enable health facilities lagging behind to learn from those on the efficiency frontier. In addition, the findings emphasise the need for CHAG to work with health facility managers to optimise inputs allocation through a redistribution of staff. Most importantly, the findings are suggestive of the resilience of CHAG health facilities in responding to a health shock such as the COVID-19 pandemic.

Self-reported symptom burden among patients attending public health care facilities in India: Looking through ICPC-3 lens.

The objectives of this study were: 1) to describe the socio-demographics and classify the chief complaints and reasons to encounter facilities of patients presenting to public healthcare facilities; 2) to explore differences in these complaints and: International Classification of Primary Care-3 (ICPC-3) groups across socio-demographic and health system levels. This is a cross-sectional study conducted in three districts of Odisha, India. Within each district, the district hospital (DH), one Sub-district hospital (SDH) (if available), two Community health centers (CHCs), and two Primary health care centers (PHCs) were selected. Thus, a total of three DHs, three SDHs, six CHCs, and six PHCs were covered. Two tertiary healthcare facilities were also included. Patients aged 18 years and older, attending the Outpatient Departments (OPD) of sampled health facilities were chosen as study participants through systematic random sampling. A total of 3044 patients were interviewed. In general, 65% of the sample reported symptoms as their chief complaint for reason of encounter, whereas 35% reported disease and diagnosis. The most common reasons to encounter health facilities were fever, hypertension, abdominal pain, chest pain, arthritis, skin disease, cough, diabetes, and injury. Among the symptoms, the highest number of patients reported the general category (29%), followed by the digestive system (16%). In the disease category, the circulatory system has the highest proportion, followed by the musculatory system. In symptom categories, general, digestive, and musculatory systems were the key systems for the reasons of encounter in outpatient departments irrespective of different groups of the population. In terms of different tiers of health systems, the top three reasons to visit OPD were dominated by the circulatory system, respiratory system, and musculatory system. This is the first Indian study using the ICPC-3 classification for all three levels of health care. Irrespective of age, socio-economic variables, and tiers of healthcare, the top three groups to visit public health facilities according to the ICPC-3 classification were consistent i.e., general, digestive, and circulatory. Implementation of standard management and referral guidelines for common diseases under these groups will improve the quality and burden at public health facilities in India.

An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria.

The availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states. We collected primary data from 50 health facilities (25 per state), including PHC facilities-health posts, health clinics, health centers-and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider's perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state. We found that average actual PHC costs per capita at PHC facilities-where most PHC services should be provided according to government guidelines-ranged from US$ 18.9 to US$ 28 in Kaduna and US$ 15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals-where approximately a third of PHC services are delivered in both states-the actual per capita costs of PHC services ranged from US$ 20 to US$ 30.6 in Kaduna and US$ 17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$ 44.9 in Kaduna and US$ 49.5 in Kano. Bridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services.

Cost of introducing and delivering malaria vaccine (RTS,S/AS01E) in areas of seasonal malaria transmission, Mali and Burkina Faso

BackgroundThe WHO recommends use of the RTS,S/AS01E (RTS,S) malaria vaccine for young children living in areas of moderate to high Plasmodium falciparum malaria transmission and suggests countries consider seasonal vaccination...

The effect of sampling health facilities on estimates of effective coverage: a simulation study

BackgroundMost existing facility assessments collect data on a sample of health facilities. Sampling of health facilities may introduce bias into estimates of effective coverage generated by ecologically linking individuals to health providers based on geographic proximity or administrative catchment.MethodsWe assessed the bias introduced to effective coverage estimates produced through two ecological linking approaches (administrative unit and Euclidean distance) applied to a sample of health facilities. Our analysis linked MICS household survey data on care-seeking for child illness and childbirth care with data on service quality collected from a census of health facilities in the Savanes region of Cote d’Ivoire. To assess the bias introduced by sampling, we drew 20 random samples of three different sample sizes from our census of health facilities. We calculated effective coverage of sick child and childbirth care using both ecological linking methods applied to each sampled facility data set. We compared the sampled effective coverage estimates to ecologically linked census-based estimates and estimates based on true source of care. We performed sensitivity analyses with simulated preferential care-seeking from higher-quality providers and randomly generated provider quality scores.ResultsSampling of health facilities did not significantly bias effective coverage compared to either the ecologically linked estimates derived from a census of facilities or true effective coverage estimates using the original data or simulated random quality sensitivity analysis. However, a few estimates based on sampling in a setting where individuals preferentially sought care from higher-quality providers fell outside of the estimate bounds of true effective coverage. Those cases predominantly occurred using smaller sample sizes and the Euclidean distance linking method. None of the sample-based estimates fell outside the bounds of the ecologically linked census-derived estimates.ConclusionsOur analyses suggest that current health facility sampling approaches do not significantly bias estimates of effective coverage produced through ecological linking. Choice of ecological linking methods is a greater source of bias from true effective coverage estimates, although facility sampling can exacerbate this bias in certain scenarios. Careful selection of ecological linking methods is essential to minimize the potential effect of both ecological linking and sampling error.

Examining the Effects of Mobile Telephone Communication on the Utilization of Antenatal Care Services Among Expectant Mothers in Kyotera And Rakai Districts, Uganda

Uganda still grapples with a high maternal mortality rates of 336 deaths per 100,000. Expectant mothers across the country lack awareness about the availability of antenatal care services; yet attendance of antenatal care services during pregnancy is crucial in protecting the health of women and unborn children. This article describes a protocol for investigating the effectiveness of mobile telephone communication interventions on the utilization of antenatal care services among expectant mothers in the districts of Kyotera and Rakai Districts in Uganda. Under the protocol, 28 health facilities in the districts of Kyotera and Rakai will be selected using simple random sampling and allocated into the intervention and control arms at a ratio of 1:1. A total of 2224 expectant mothers receiving antenatal care from the sampled health facilities will be recruited using systematic sampling. Expectant mothers receiving antenatal care from facilities allocated into the intervention arm will receive mobile telephone voice and text messages reminders for scheduled ANC visits. The mobile telephone messages will further provide maternal health information and availability of ANC services on a fortnightly basis. On the other hand, expectant mothers receiving antenatal care from facilities allocated into the control group will not get any reminders for scheduled ANC visit and maternal health information through the mobile telephone communication platform. Expectant mothers in the control arm will receive standard maternal health care without reminders. Expectant mothers in both groups will provide baseline data, midterm data will be obtained from the ANC registers at 6 moths while end of term data will be collected after an intervention period of 12months. The data collected will include the number of antenatal care visits attended, antenatal care services obtained from the health facilities, sociodemographic factors and mobile telephone usage, ownership and knowledge. The anticipated outcomes are; increased awareness and utilization of ANC services.

Investigation of technical quality of antenatal and perinatal services in a nationally representative sample of health facilities in Nepal

BackgroundAccess to routine antenatal and perinatal services is improved in the last two decades in Nepal. However, gaps remain in coverage and quality of care delivered from the health facilities. This study investigated the delivery of technical quality antenatal and perinatal services from health facilities and their associated determinants in Nepal.MethodsData for this study were derived from the Nepal Health Facility Survey 2015. The World Health Organization's Service Availability and Readiness Assessment framework was adopted to assess the technical quality of antenatal and perinatal services of health facilities. Outcome variables included technical quality scores of i) 269 facilities providing antenatal services and ii) 109 facilities providing childbirth and postnatal care services (perinatal care). Technical quality scores of health facilities were estimated adapting recommended antenatal and perinatal interventions. Independent variables included locations and types of health facilities and their management functions (e.g., supervision). We conducted a linear regression analysis to identify the determinants of better technical quality of health services in health facilities. Beta coefficients were exponentiated into odds ratios (ORs) and reported with 95% confidence intervals (CIs). The significance level was set at p-value < 0.05.ResultsThe mean score of the technical quality of health facilities for each outcome variable (antenatal and perinatal services) was 0.55 (out of 1.00). Compared to province one, facilities of Madhesh province had 4% lower odds (adjusted OR = 0.96; 95%CI: 0.92, 0.99) of providing better quality antenatal services, while health facilities of Gandaki province had higher odds of providing better quality antenatal services (aOR = 1.05; 95% CI: 1.01, 1.10). Private facilities had higher odds (aOR = 1.13; 95% CI: 1.03, 1.23) of providing better quality perinatal services compared to public facilities.ConclusionsPrivate facilities provide better quality antenatal and perinatal health services than public facilities, while health facilities of Madhesh province provide poor quality perinatal services. Health system needs to implement tailored strategies, including recruiting health workers, supervision and onsite coaching and access to necessary equipment and medicine in the facilities of Madhesh province. Health system inputs (trained human resources, equipment and supplies) are needed in the public facilities. Extending the safe delivery incentive programme to the privately managed facilities could also improve access to better quality health services in Nepal.

Barriers and facilitators to timely birth-dose vaccines in Kinshasa Province, the DRC: a qualitative study

Background National vaccine policies across the world have successfully improved infant vaccine coverage, but birth-dose (BD) vaccine coverage remains low. Countries such as the Democratic Republic of the Congo (DRC) aim to include the hepatitis B birth-dose (HepB-BD) vaccine in their national immunization schedule. HepB-BD’s short window for administration – within 24 hours of delivery to prevent mother-to-child transmission – adds to the complexity of streamlined and timely BD vaccines. This study aims to identify and understand barriers and facilitators to timely delivery of BD vaccine in Kinshasa Province, DRC, through individuals’ accounts with different perspectives on the uptake of the BD vaccine in preparation for its future roll-out. Methods We conducted semi-structured interviews in seven health facilities across Kinshasa Province from June to July 2021. We purposefully sampled health facilities from the provinces’ five most prominent facility types—private, public, Catholic, Protestant, and not-for-profit. We interviewed decision-makers and/or providers from various levels of the health care continuum, including midwives, immunization staff, heads of maternity and immunizations, and vaccine officials at the health zone and the Programme Elargi de Vaccination (PEV) to understand administrative barriers to BD vaccines. We also conducted interviews with expectant mothers to elicit knowledge and perceptions about infant vaccines. Results We interviewed 30 participants (16 informants and 14 expectant mothers). Interviewees were recruited from 7 health facilities, 2 health zones, and PEV. Data analysis was guided by the Consolidated Framework for Implementation Research (CFIR). Our analysis identified 13 constructs (2-3 per domain) related to the success of timely and streamlined BD vaccines. We found significant barriers within and across each domain; most notably, the multi-dose vials of existing BD vaccines determining when facility staff could vaccinate newborns, often resulting in untimely vaccinations; logistical concerns with regular national vaccine stockouts and ability to store vaccines; complex and unsynchronized vaccine fees across facilities; inadequate communication across delivery and vaccination wards; and limited and at times incorrect understanding of vaccines among mothers and other community members. Conclusions Using the CFIR framework, this study integrated perspectives from facility informants and expectant mothers to inform national policy and implementation of the HepB-BD in DRC. These stakeholder-driven findings should guide the streamlining of timely BD vaccinations upon HepB-BD implementation.

Geostatistical linkage of national demographic and health survey data: a case study of Tanzania

BackgroundWhen Service Provision Assessment (SPA) surveys on primary health service delivery are combined with the nationally representative household survey—Demographic and Health Survey (DHS), they can provide key information on the access, utilization, and equity of health service availability in low- and middle-income countries. However, existing linkage methods have been established only at aggregate levels due to known limitations of the survey datasets.MethodsFor the linkage of two data sets at a disaggregated level, we developed a geostatistical approach where SPA limitations are explicitly accounted for by identifying the sites where health facilities might be present but not included in SPA surveys. Using the knowledge gained from SPA surveys related to the contextual information around facilities and their spatial structure, we made an inference on the service environment of unsampled health facilities. The geostatistical linkage results on the availability of health service were validated using two criteria—prediction accuracy and classification error. We also assessed the effect of displacement of DHS clusters on the linkage results using simulation.ResultsThe performance evaluation of the geostatistical linkage method, demonstrated using information on the general service readiness of sampled health facilities in Tanzania, showed that the proposed methods exceeded the performance of the existing methods in terms of both prediction accuracy and classification error. We also found that the geostatistical linkage methods are more robust than existing methods with respect to the displacement of DHS clusters.ConclusionsThe proposed geospatial approach minimizes the methodological issues and has potential to be used in various public health research applications where facility and population-based data need to be combined at fine spatial scale.

Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal 'treat-all' policies: A competing risk analysis.

As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016-pre-treat-all era, and July 2016 to June 2017-treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90-1.56) versus treat-all period IR = 1.62 (95%CI: 1.37-1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05-2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.

Preconception Care Utilization among Childbearing Women in South-East Nigeria

Adverse pregnancy outcomes remain a challenging health problem in Nigeria. Before conception, couples need to utilize preconception care which is meant to address most of the reproductive health risks. However, the use of this service and its determinants is not well investigated globally. This Cross-sectional study was aimed at assessing the utilization of preconception care and its determinants among mothers in South-East Nigeria. Pre-tested and validated structured Questionnaire on Preconception Care Utilization was used to collect data from 350 postnatal women who were systematically selected from 33 sampled health facilities. Data were collated and entered into SPSS version 20. Binary logistic regression was used to determine the association between the demographic characteristics of the mothers and the utilization of preconception care. Statistical significance was set at p&lt;0.05. Results show that only 23.4% of the mothers utilized preconception care. Parity, employment status, and pregnancy intention were significantly associated with preconception care utilization. The odd of utilizing preconception care were 60.2% lower among multiparous women than primiparous women. Working-class mothers were more than 70% less likely to utilize preconception care than mothers who were not employed. Mothers whose pregnancy was intended were 3.4 times more likely to utilized preconception care than mothers whose pregnancy was unintended. Health facilities should establish functional clinics with the availability of evidence-based guidelines to improve uptake of preconception care. Health care professionals should intensify their efforts in encouraging women to receive preconception care.

Performance of passive case detection for malaria surveillance: results from nine countries in Mesoamerica and the Dominican Republic

BackgroundIn malaria elimination settings, available metrics for malaria surveillance have been insufficient to measure the performance of passive case detection adequately. An indicator for malaria suspected cases with malaria test (MSCT) is proposed to measure the rate of testing on persons presenting to health facilities who satisfy the definition of a suspected malaria case. This metric does not rely on prior knowledge of fever prevalence, seasonality, or external denominators, and can be used to compare detection rates in suspected cases within and between countries, including across settings with different levels of transmission.MethodsTo compute the MSCT, an operational definition for suspected malaria cases was established, including clinical and epidemiological criteria. In general, suspected cases included: (1) persons with fever detected in areas with active malaria transmission; (2) persons with fever identified in areas with no active transmission and travel history to, or residence in areas with active transmission (either national or international); and (3) persons presenting with fever, chills and sweating from any area. Data was collected from 9 countries: Belize, Colombia (in areas with active transmission), Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama (September–March 2020). A sample of eligible medical records for 2018 was selected from a sample of health facilities in each country. An algorithm was constructed to assess if a malaria test was ordered or performed for cases that met the suspected case definition.ResultsA sample of 5873 suspected malaria cases was obtained from 239 health facilities. Except for Nicaragua and Colombia, malaria tests were requested in less than 10% of all cases. More cases were tested in areas with active transmission than areas without cases. Travel history was not systematically recorded in any country.ConclusionsA statistically comparable, replicable, and standardized metric was proposed to measure suspected malaria cases with a test (microscopy or rapid diagnostic test) that enables assessing the performance of passive case detection. Cross-country findings have important implications for malaria and infectious disease surveillance, which should be promptly addressed as countries progress towards malaria elimination. Local and easy-to-implement tools could be implemented to assess and improve passive case detection.

Treatment success for patients with tuberculosis receiving care in areas severely affected by Hurricane Matthew - Haiti, 2016.

On October 4, 2016, Hurricane Matthew struck southwest Haiti as a category 4 storm. The goal of this study was to evaluate the impact of the hurricane on tuberculosis (TB) services and patient outcomes in the three severely affected departments-Sud, Grand'Anse, and Nippes-of southwest Haiti. We developed a standard questionnaire to assess a convenience sample of health facilities in the affected areas, a patient tracking form, and a line list for tracking all patients with drug-susceptible TB registered in care six months before the hurricane. We analyzed data from the national TB electronic surveillance system to determine outcomes for all patients receiving anti-TB treatment in the affected areas. We used logistic regression analysis to determine factors associated with treatment success. Of the 66 health facilities in the three affected departments, we assessed 31, accounting for 536 (45.7%) of 1,174 TB patients registered in care when Hurricane Matthew made landfall in Haiti. Three (9.7%) health facilities sustained moderate to severe damage, whereas 18 (58.1%) were closed for <1 week, and five (16.1%) for ≥1 week. Four weeks after the hurricane, 398 (73.1%) of the 536 patients in the assessed facilities were located. Treatment success in the affected departments one year after the hurricane was 81.4%. Receiving care outside the municipality of residence (adjusted odds ratio [aOR]: 0.46, 95% confidence interval [CI]: 0.27-0.80) and HIV positivity (aOR: 0.31, 95% CI: 0.19-0.51) or unknown HIV status (aOR: 0.49, 95% CI: 0.33-0.74) were associated with significantly lower rates of treatment success. Despite major challenges, a high percentage of patients receiving anti-TB treatment before the hurricane were located and successfully treated in southwest Haiti. The lessons learned and results presented here may help inform policies and guidelines in similar settings for effective TB control after a natural disaster.

Hybrid Approach to Estimation of Underreporting of Tuberculosis Case Notification in High-Burden Settings With Weak Surveillance Infrastructure: Design and Implementation of an Inventory Study

BackgroundThe greatest risk of infectious disease undernotification occurs in settings with limited capacity to detect it reliably. World Health Organization guidance on the measurement of misreporting is paradoxical, requiring robust, independent systems to assess surveillance rigor. Methods are needed to estimate undernotification in settings with incomplete, flawed, or weak surveillance systems. This study attempted to design a tuberculosis (TB) inventory study that balanced rigor with feasibility for high-need settings.ObjectiveThis study aims to design a hybrid TB inventory study for contexts without World Health Organization preconditions. We estimated the proportion of TB cases that were not reported to the Ministry of Health in 2015. The study sought to describe TB surveillance coverage and quality at different levels of TB care provision. Finally, we aimed to identify structural-, facility-, and provider-level barriers to notification and reasons for underreporting, nonreporting, and overreporting.MethodsRetrospective partial digitalization of paper-based surveillance and facility records preceded deterministic and probabilistic record linkage; a hybrid of health facilities and laboratory census with a stratified sampling of HFs with no capacity to notify leveraged a priori knowledge. Distinct extrapolation methods were applied to the sampled health facilities to estimate bacteriologically confirmed versus clinical TB. In-depth interviews and focus groups were used to identify causal factors responsible for undernotification and test the acceptability of remedies.ResultsThe hybrid approach proved viable and instructive. High-specificity verification of paper-based records in the field was efficient and had minimal errors. Limiting extrapolation to clinical cases improved precision. Probabilistic record linkage is computationally intensive, and the choice of software influences estimates. Record absence, decay, and overestimation of the private sector TB treatment behavior threaten validity, meriting mitigation. Data management demands were underestimated. Treatment success was modest in all sectors (R=37.9%–72.0%) and did not align with treatment success reported by the state (6665/8770, 75.99%). One-fifth of TB providers (36/178, 20%) were doubtful that the low volume of patients with TB treated in their facility merited mastery of the extensive TB notification forms and procedures.ConclusionsSubnational inventory studies can be rigorous, relevant, and efficient in countries that need them even in the absence of World Health Organization preconditions, if precautions are taken. The use of triangulation techniques, with minimal recourse to sampling and extrapolation, and the privileging of practical information needs of local decision makers yield reasonable misreporting estimates and viable policy recommendations.

Evaluation of neonatal mortality data completeness and accuracy in Ghana.

Cause-specific mortality data are required to set interventions to reduce neonatal mortality. However, in many developing countries, these data are either lacking or of low quality. We assessed the completeness and accuracy of cause of death (COD) data for neonates in Ghana to assess their usability for monitoring the effectiveness of health system interventions aimed at improving neonatal survival. A lot quality assurance sampling survey was conducted in 20 hospitals in the public sector across four regions of Ghana. Institutional neonatal deaths (IND) occurring from 2014 through 2017 were divided into lots, defined as neonatal deaths occurring in a selected facility in a calendar year. A total of 52 eligible lots were selected: 10 from Ashanti region, and 14 each from Brong Ahafo, Eastern and Volta region. Nine lots were from 2014, 11 from 2015 and 16 each were from 2016 and 2017. The cause of death (COD) of 20 IND per lot were abstracted from admission and discharge (A&D) registers and validated against the COD recorded in death certificates, clinician's notes or neonatal death audit reports for consistency. With the error threshold set at 5%, ≥ 17 correctly matched diagnoses in a sample of 20 deaths would make the lot accurate for COD diagnosis. Completeness of COD data was measured by calculating the proportion of IND that had death certificates completed. Nineteen out of 52 eligible (36.5%) lots had accurate COD diagnoses recorded in their A&D registers. The regional distribution of lots with accurate COD data is as follows: Ashanti (4, 21.2%), Brong Ahafo (7, 36.8%), Eastern (4, 21.1%) and Volta (4, 21.1%). Majority (9, 47.4%) of lots with accurate data were from 2016, followed by 2015 and 2017 with four (21.1%) lots. Two (10.5%) lots had accurate COD data in 2014. Only 22% (239/1040) of sampled IND had completed death certificates. Death certificates were not reliably completed for IND in a sample of health facilities in Ghana from 2014 through 2017. The accuracy of cause-specific mortality data recorded in A&D registers was also below the desired target. Thus, recorded IND data in public sector health facilities in Ghana are not valid enough for decision-making or planning. Periodic data quality assessments can determine the magnitude of the data quality concerns and guide site-specific improvements in mortality data management.

Assessing service availability and readiness to manage Chronic Respiratory Diseases (CRDs) in Bangladesh.

Chronic Respiratory Diseases (CRDs) are some of the most prevailing non-communicable diseases (NCDs) worldwide and cause three times higher morbidity and mortality in low- and middle-income countries (LMIC) than in developed nations. In Bangladesh, there is a dearth of data about the quality of CRD management in health facilities. This study aims to describe CRD service availability and readiness at all tiers of health facilities using the World Health Organization's (WHO) Service Availability and Readiness Assessment (SARA) tool. A cross-sectional study was conducted from December 2017 to June 2018 in a total of 262 health facilities in Bangladesh using the WHO SARA Standard Tool. Surveys were conducted with facility management personnel by trained data collectors using REDCap software. Descriptive statistics for the availability of CRD services were calculated. Composite scores for facility readiness (Readiness Index 'RI') were created which included four domains: staff and guideline, basic equipment, diagnostic capacity, and essential medicines. RI was calculated for each domain as the mean score of items expressed as a percentage. Indices were compared to a cutoff of70% which means that a facility index above 70% is considered 'ready' to manage CRDs at that level. Data analysis was conducted using SPSS Vr 21.0. It was found, tertiary hospitals were the only hospitals that surpassed the readiness index cutoff of 70%, indicating that they had adequate capacity and were ready to manage CRDs (RI 78.3%). The mean readiness scores for the other hospital tiers in descending order were District Hospitals (DH): 40.6%, Upazila Health Complexes (UHC): 33.3% and Private NGOs: 39.5%). Only tertiary care hospitals, constituting 3.1% of sampled health facilities, were found ready to manage CRD. Inadequate and unequal supplies of medicine as well as a lack of trained staff, guidelines on the diagnosis and treatment of CRDs, equipment, and diagnostic facilities contributed to low readiness index scores in all other tiers of health facilities.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 2: Review of the results of quality cycles and of factors influencing change.

BackgroundInformation about the use of the findings of quality assessments in maternal and neonatal (MN) care is lacking and the development of tools capable to effectively address quality gaps is a key priority. Furthermore, little is known about factors that act as barriers or facilitators to change at facility level. Based on the extensive experience made with the WHO Quality Assessment and Improvement MN (QA/QI MN) tool, an overview is provided of the improvements in quality of care (QoC) which were obtained over time and of the factors influencing change.MethodsAll documented reports on the implementation of the WHO QA/QI MN tool were searched and screened for inclusion. Reports were considered if bringing evidence from both the baseline assessment and the reassessment. Changes were considered in four domains: maternal care, neonatal care, infrastructure and policies, with reference made to WHO maternal and neonatal care standards. The observed improvements were categorized according to intensity and extent across the sample of health facilities. Factors influencing change were categorized into internal and external and further classified as barriers or facilitators.ResultsChanges were documented after an average period of 1.2 years from first assessment in 27 facilities belonging to 9 different countries in Central and Eastern Europe (3), Central Asia (3), sub-Saharan Africa (2) and Latin America (1). Improvements were observed in all areas of care but were greater and more frequently observed in areas related to appropriate case management and respectful care for both mothers and newborns. Although widespread across most facilities and countries, the observed improvements were not covering all the quality gaps observed at the baseline assessment nor were always sufficient to achieve standard care. Factors facilitating change as well as barriers were mainly related to the capacity of the managers and head of units to involve and motivate their staff members.ConclusionsThe use of WHO QA/QI MN tool proved effective in promoting significant changes in quality of care. The review of observed improvements and of factors influencing change at facility level shows that participatory assessment tools that promote a constructive dialogue with hospital managers and staff and support them in acquiring capacity in this role are crucial to implement effective quality cycles.

Factors affecting the technical efficiency of rural primary health care centers in Hamadan, Iran: data envelopment analysis and Tobit regression

BackgroundStudying and monitoring the efficiency of primary health care centers has a special place in the health system. Although studies have been conducted in the field of efficiency in Iran, few have focused on rural primary health care centers. In addition, previous studies have not used the child mortality rate and Behvarzes as input and output.ObjectiveThe present study was conducted aimed to estimate the technical efficiency of rural primary health care centers and determinant factors in Hamadan using data envelopment analysis and Tobit regression.MethodsThis is a Longitudinal study of rural primary health care centers in Hamadan province (2002–2016). Data Envelopment Analysis was employed to estimate technical efficiency of sampled health facilities while Panel Tobit Analysis was applied to predict factors associated with efficiency levels. The outputs were child mortality rate under 1 year of age and child mortality rate 1 year to 5 years of age. The input was Behvarzes (rural health workers).ResultsThe results of efficiency analysis showed that the average efficiency scores of the centers had a fluctuating trend during the period of the study, but the average performance scores generally decreased in 2016, as compared with 2002. The highest and lowest average performance scores were observed in 2003 (0.78) and 2013 (0.56), respectively. Number of physicians and rural primary healthcare centers per population had a positive statistically significant and the number of midwives and the total fertility per population had a negative statistically significant effect on efficiency.ConclusionsThe findings suggest some level of wastage of health resources in primary health centers. Findings indicate a level of waste of health resources in primary health centers. Behvarz functions in providing primary care services can be considered in the reallocation and optimal use of available resources at the level of rural health centers.

Using health facility deaths to estimate population causes of neonatal and child mortality in four African countries

BackgroundVerbal autopsy is the main method used in countries with weak civil registration systems for estimating community causes of neonatal and 1–59-month-old deaths. However, validation studies of verbal autopsy methods are limited and assessment has been dependent on hospital-based studies, with uncertain implications for its validity in community settings. If the distribution of community deaths by cause was similar to that of facility deaths, or could be adjusted according to related demographic factors, then the causes of facility deaths could be used to estimate population causes.MethodsCauses of neonatal and 1–59-month-old deaths from verbal/social autopsy (VASA) surveys in four African countries were estimated using expert algorithms (EAVA) and physician coding (PCVA). Differences between facility and community deaths in individual causes and cause distributions were examined using chi-square and cause-specific mortality fractions (CSMF) accuracy, respectively. Multinomial logistic regression and random forest models including factors from the VASA studies that are commonly available in Demographic and Health Surveys were built to predict population causes from facility deaths.ResultsLevels of facility and community deaths in the four countries differed for one to four of 10 EAVA or PCVA neonatal causes and zero to three of 12 child causes. CSMF accuracy for facility compared to community deaths in the four countries ranged from 0.74 to 0.87 for neonates and 0.85 to 0.95 for 1–59-month-olds. Crude CSMF accuracy in the prediction models averaged 0.86 to 0.88 for neonates and 0.93 for 1–59-month-olds. Adjusted random forest prediction models increased average CSMF accuracy for neonates to, at most, 0.90, based on small increases in all countries.ConclusionsThere were few differences in facility and community causes of neonatal and 1–59-month-old deaths in the four countries, and it was possible to project the population CSMF from facility deaths with accuracy greater than the validity of verbal autopsy diagnoses. Confirmation of these findings in additional settings would warrant research into how medical causes of deaths in a representative sample of health facilities can be utilized to estimate the population causes of child death.

Female clients\u2019 gender preferences for frontline health workers who provide maternal, newborn and child health (MNCH) services at primary health care level in Nigeria

BackgroundIn Nigeria, anecdotes abound that female clients, particularly within northern Nigeria, have gender-based preferences for frontline health workers (FLHWs) who provide healthcare services. This may adversely affect uptake of maternal newborn and child health services, especially at primary healthcare level in Nigeria, where a huge proportion of the Nigerian population and rural community members in particular, access healthcare services. This study explored female clients’ gender preferences for frontline health workers who provide maternal, newborn and child healthcare (MNCH) services at primary healthcare level in Nigeria.MethodsThe study adopted a cross-sectional quantitative design with 256 female clients’ exit interviews from selected primary health facilities within two States - Bauchi (northern Nigeria) and Cross-River (southern Nigeria). Data was collected using Personal Digital Assistants and data analysis was done using SPSS software. Descriptive analysis was carried out using percentage frequency distribution tables. Bivariate analysis was also carried out to examine possible relationships between key characteristic variables and the gender preferences of female clients involved in the study.ResultsOut of 256 women who accessed maternal, newborn and child health services within the sampled health facilities, 44.1% stated preference for female FLHWs, 2.3% preferred male FLHWs while 53.5% were indifferent about the gender of the health worker. However only 26.6% of female clients were attended to by male FLHWs. Bivariate analysis suggests a relationship between a female client’s health worker gender preference and her pregnancy status, the specific reason for which a female client visits a primary healthcare facility, a female client’s location in Nigeria as well as the gender of the health worker(s) working within the primary healthcare facility which she visits to access maternal, newborn and child health services.ConclusionsThe study findings suggest that female clients at primary healthcare level in Nigeria possibly have gender preferences for the frontline health workers who provide services to them. There should be sustained advocacy and increased efforts at community engagement to promote the acceptability of healthcare services from male frontline health workers in order to have a significant impact on the uptake of MNCH services, particularly within northern Nigeria.