Health System Quality and Improvement Strategies in Caring for People With HIV and Cardiovascular Diseases: Studies From Tanzania, Uganda, and China

Abstract

Delivery of health care services that meet evidence-based standards and are responsive to people’s health needs is core to achieving universal health coverage (UHC). Non-communicable diseases (NCDs) have now overtaken communicable diseases as the number one cause of mortality and morbidity in a majority of low- and middle-income countries (LMICs). Despite the availability of guidelines and growing access to clinics, large numbers of people in LMICs do not receive high-quality health care services. Measurement of health system quality is also problematic, as nationally representative data on quality of care and disparities in quality across population subgroups and social groups are limited, and quality itself is poorly understood. My dissertation addresses health system quality in the treatment of chronic diseases. It is constituted of three papers that analyze each one element underlying quality: measurement, improvement, and equity. In paper one, I evaluate predictive validity of a measure of process quality; in paper two, I model a strategy for system improvements through integration of care; and in paper three, I analyze the distribution in good quality care to inform health system policies in middle-income countries. The first two study settings are located in sub-Saharan Africa, and the third study setting is China, a middle-income country that can provide useful lessons for health system improvement in low-income settings of sub-Saharan Africa. Specifically, the first study uses data from a cohort of HIV patients in Tanzania to develop and validate facility-level process measures of quality of HIV care. The second study uses data from a nationally representative survey of NCD risk factors (hypertension, diabetes mellitus, high cholesterol) in Uganda to model the impact and cost-effectiveness of integrating basic NCD care within HIV treatment delivery services to improve the health outcomes of people living with HIV receiving antiretroviral therapy. The third study uses data from nationally representative surveys of health facilities in China to examine the variation in quality of care provided to patients admitted to hospitals with acute myocardial infarction. Together, these three analyses contribute evidence towards formulating strategies to address the urgent problem of low-quality and inequitable care for chronic diseases in LMICs.