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dc.contributor.authorLeslie, Hannah H.en_US
dc.contributor.authorSun, Zeyeen_US
dc.contributor.authorKruk, Margaret E.en_US
dc.date.accessioned2018-01-18T02:31:41Z
dc.date.issued2017en_US
dc.identifier.citationLeslie, Hannah H., Zeye Sun, and Margaret E. Kruk. 2017. “Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries.” PLoS Medicine 14 (12): e1002464. doi:10.1371/journal.pmed.1002464. http://dx.doi.org/10.1371/journal.pmed.1002464.en
dc.identifier.issnen
dc.identifier.urihttp://nrs.harvard.edu/urn-3:HUL.InstRepos:34652025
dc.description.abstractBackground: It is increasingly apparent that access to healthcare without adequate quality of care is insufficient to improve population health outcomes. We assess whether the most commonly measured attribute of health facilities in low- and middle-income countries (LMICs)—the structural inputs to care—predicts the clinical quality of care provided to patients. Methods and findings Service Provision Assessments are nationally representative health facility surveys conducted by the Demographic and Health Survey Program with support from the US Agency for International Development. These surveys assess health system capacity in LMICs. We drew data from assessments conducted in 8 countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda. The surveys included an audit of facility infrastructure and direct observation of family planning, antenatal care (ANC), sick-child care, and (in 2 countries) labor and delivery. To measure structural inputs, we constructed indices that measured World Health Organization-recommended amenities, equipment, and medications in each service. For clinical quality, we used data from direct observations of care to calculate providers’ adherence to evidence-based care guidelines. We assessed the correlation between these metrics and used spline models to test for the presence of a minimum input threshold associated with good clinical quality. Inclusion criteria were met by 32,531 observations of care in 4,354 facilities. Facilities demonstrated moderate levels of infrastructure, ranging from 0.63 of 1 in sick-child care to 0.75 of 1 for family planning on average. Adherence to evidence-based guidelines was low, with an average of 37% adherence in sick-child care, 46% in family planning, 60% in labor and delivery, and 61% in ANC. Correlation between infrastructure and evidence-based care was low (median 0.20, range from −0.03 for family planning in Senegal to 0.40 for ANC in Tanzania). Facilities with similar infrastructure scores delivered care of widely varying quality in each service. We did not detect a minimum level of infrastructure that was reliably associated with higher quality of care delivered in any service. These findings rely on cross-sectional data, preventing assessment of relationships between structural inputs and clinical quality over time; measurement error may attenuate the estimated associations. Conclusion: Inputs to care are poorly correlated with provision of evidence-based care in these 4 clinical services. Healthcare workers in well-equipped facilities often provided poor care and vice versa. While it is important to have strong infrastructure, it should not be used as a measure of quality. Insight into health system quality requires measurement of processes and outcomes of care.en
dc.language.isoen_USen
dc.publisherPublic Library of Scienceen
dc.relation.isversionofdoi:10.1371/journal.pmed.1002464en
dc.relation.hasversionhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726617/pdf/en
dash.licenseLAAen_US
dc.subjectMedicine and Health Sciencesen
dc.subjectWomen's Healthen
dc.subjectMaternal Healthen
dc.subjectAntenatal Careen
dc.subjectHealth Careen
dc.subjectQuality of Careen
dc.subjectPublic and Occupational Healthen
dc.subjectGlobal Healthen
dc.subjectEngineering and Technologyen
dc.subjectEquipmenten
dc.subjectPeople and Placesen
dc.subjectGeographical Locationsen
dc.subjectAfricaen
dc.subjectKenyaen
dc.subjectMalawien
dc.subjectRwandaen
dc.subjectHealth Care Facilitiesen
dc.titleAssociation between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countriesen
dc.typeJournal Articleen_US
dc.description.versionVersion of Recorden
dc.relation.journalPLoS Medicineen
dash.depositing.authorLeslie, Hannah H.en_US
dc.date.available2018-01-18T02:31:41Z
dc.identifier.doi10.1371/journal.pmed.1002464*
dash.contributor.affiliatedLeslie, Hannah
dash.contributor.affiliatedKruk, Margaret


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