Three Studies on Improving Health System Performance

Abstract

In this dissertation, I address three issues related to health system performance and the policy-related questions concerning patients, providers, and payers: (1) health gains and financial risk protection benefits for households of rolling out malaria vaccine in Zambia; (2) association between sick child care utilization and health facility quality in Malawi; (3) association between system features of primary care practice and provider experiences. Chapter One presents an overview as well as key insights from all three studies. In Chapter Two, by employing the extended cost-effectiveness analysis (ECEA) methodology, I investigated the health and financial consequences of malaria vaccination in Zambia. For one birth cohort (from 2016), this research found that a national malaria vaccination program would yield significant health benefits with malaria deaths averted, greatly reduce malaria-related OOP expenditures, and prevent a large number of catastrophic health expenditure cases among households as compared to without malaria vaccination. In Chapter Three, this study examined the role of health facility quality with regard to sick child care service utilization by caregivers in Malawi, using data from Malawi’s nationally-representative health facility and household surveys. Results suggested that, although curative child care is widely available in a great number of health facilities in Malawi, quality and utilization are still in short supply. The results of this study suggested that better facility quality would drive caregivers of childhood illness to utilize health facilities. In Chapter Four, I explored system features of primary care practice sites associated with better provider experiences of care and clinical work satisfaction, using data from cross-sectional surveys conducted in primary care practices affiliated with the Harvard Academic Innovations Collaborative and employing a novel methodology, qualitative comparative analysis (QCA). The results suggested that provider-perceived strong safety culture, combined with favorable team dynamics, contributed most to greater clinical work satisfaction among primary care providers. This study also found that having system features that identify urgent or complex acute illness and that manage collaborations among primary care providers across institutional settings may be the conditions that best enhance their clinical work satisfaction.