Health System Quality Improvement Strategies in Sub-Saharan Africa: Implementation and Impact

Abstract

Poor quality health systems are increasingly recognized as a major barrier to achieving universal health coverage and improved health outcomes in Sub-Saharan Africa. As the extent and degree of poor-quality care has been documented in recent years, improving health system quality is a growing priority. Quality improvement interventions may act in non-linear ways because they are implemented within the context of complex adaptive health systems, where interconnected components allow for feedback loops, learning, and adaptation. The three papers comprising this dissertation explore healthcare quality improvement in Sub-Saharan Africa through a complex adaptive system lens, examining interventions at the macro, meso and micro levels of the health system. Maternal and newborn care has been a primary focus of performance-based financing (PBF) projects across Sub-Saharan Africa, however there is a lack of evidence of the effect of PBF on neonatal health outcomes. Chapter 2 uses a difference-in-differences study design with secondary data to assess the impact of PBF on early neonatal health outcomes and associated health care utilization and quality in Burundi, Lesotho, Senegal, Zambia, and Zimbabwe. PBF had no detectable impacts on neonatal mortality or low birthweight and had limited and variable effects on the utilization and quality of neonatal health care. This study highlights the necessity of assessing health impacts directly and suggests other strategies will be necessary to improve newborn health outcomes. Chapter 3 explores a national primary care quality improvement intervention in Tanzania, the Star Rating Assessment, in which primary care facilities received data, feedback and guidance to improve their quality of care. Across two rounds of data collection, there was varied levels of improvement across facilities. This study identifies contextual factors associated with facility quality improvement, finding that improvement was associated with community demand, external policies, and baseline quality levels. Geographic clustering in improvement was not completely explained by administrative boundaries, suggesting that nearby facilities may also play a role in spurring improvement. The results highlight that the facility’s setting can promote or inhibit quality improvement as much as internal facility management and organization. In Ethiopia, the quality of routine maternal and neonatal care needs to be improved to address lingering mortality and morbidity. Multiple providers often attend a single delivery over the course of labor, intrapartum and postpartum periods, particularly in larger health facilities, with unknown consequences for the quality of care. Chapter 4 explores how multiple providers work together to provide quality care using detailed observations of deliveries collected in Dire Dawa Administration, Ethiopia. The number of providers attending a delivery was unassociated with quality of care but working with coworkers who provide higher quality of care was modestly associated with better adherence to routine care guidelines. This study suggests that quality improvement interventions should take account of team structures and leverage provider relationships to create positive spillovers for quality of care. Together, these three studies show promising opportunities for addressing the enormous gaps in health system quality in sub-Saharan Africa. Findings can be used to harness the feedback loops and dynamic relationships inherent in health systems to magnify the potential impact of quality improvement and to harmonize improvement at the macro, meso and micro levels for better population health.