Effective coverage of primary care services in eight high-mortality countries

Abstract

IntroductionMeasurement of effective coverage (quality-corrected coverage) of essential health services is critical to monitoring progress towards the Sustainable Development Goal for health. We combine facility and household surveys from eight low-income and middle-income countries to examine effective coverage of maternal and child health services.MethodsWe developed indices of essential clinical actions for antenatal care, family planning and care for sick children from existing guidelines and used data from direct observations of clinical visits conducted in Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania and Uganda between 2007 and 2015 to measure quality of care delivered. We calculated healthcare coverage for each service from nationally representative household surveys and combined quality with utilisation estimates at the subnational level to quantify effective coverage.ResultsHealth facility and household surveys yielded over 40 000 direct clinical observations and over 100 000 individual reports of healthcare utilisation. Coverage varied between services, with much greater use of any antenatal care than family planning or sick-child care, as well as within countries. Quality of care was poor, with few regions demonstrating more than 60% average performance of basic clinical practices in any service. Effective coverage across all eight countries averaged 28% for antenatal care, 26% for family planning and 21% for sick-child care. Coverage and quality were not strongly correlated at the subnational level; effective coverage varied by as much as 20% between regions within a country.ConclusionEffective coverage of three primary care services for women and children in eight countries was substantially lower than crude service coverage due to major deficiencies in care quality. Better performing regions can serve as examples for improvement. Systematic increases in the quality of care delivered—not just utilisation gains—will be necessary to progress towards truly beneficial universal health coverage.

Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi?

“…Our results cast doubt on such an outcome in Burundi: overall, our study found a consistently poor level of adherence on IMCI guidelines by HWs, which is likely to affect the quality of care for their patients. This low compliance is consistent with evaluations of IMCI case management practices in several other settings [20][21][22][23] and other studies in the field of quality of care for sick children [24]. This finding indicates a missed opportunity to benefit Burundi's children given that some studies have reported that IMCI is associated with improvements in the quality of health care [25][26][27].…”

Linking household survey and health facility data for effective coverage measures: a comparison of ecological and individual linking methods using the Multiple Indicator Cluster Survey in Côte d’Ivoire

“…Other studies have also found large gaps between coverage of care-seeking and effective or quality-adjusted coverage: for example Marchant et al found in 3 settings that quality coverage of ANC was 82%-93% lower than overall ANC coverage, and quality coverage of delivery was 41%-53% lower than overall coverage of institutional delivery [7]. Leslie et al found that across 8 countries, effective coverage of ANC was 44% lower than ANC4, and effective coverage of sick child care 62% lower than care-seeking for sick children [10]. These findings highlight the work that remains in ensuring that effective interventions, delivered with high quality, reach individuals in need.…”

Variance estimation for effective coverage measures: A simulation study

“…In 2016, the WHO released guidelines that increased the recommended contacts to eight visits [10], although this has not yet been widely adopted as a measure of coverage. Studies on quality-adjusted coverage have used both one visit and four visits to quantify ANC coverage, which is based typically on maternal self-report in household surveys [11][12][13][14][15][16][17][18][19]. Facility measures have similarly followed WHO guidance on the expectations for ANC and have generally focused on inputs to care, with studies that define structural quality measures for health facilities such as functional diagnostics and medications [11,15,16].…”