A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil

INTRODUCTION: This study presents a methodology for the rapid assessment of the organization and performance of primary care services at district level. It compares results from an earlier provider survey in Petrópolis, Brazil with those obtained directly from users of two types of primary care services (newly developed Family Health Program services or 'PSF'--Programa de Saúde da Família--and traditional services) in the same municipality. The aim is to demonstrate the validity of the methodology and its potential use in measuring and improving district-level primary care services in developing countries. METHODS: The study adapted a previously developed questionnaire to measure essential dimensions of primary care. Users (n = 468) were randomly selected from each of the 40 primary care clinics in the district and administered a question survey. Responses were used to create nine measures: an overall composite 'total primary care index' and eight sub-indices each pertaining to an essential primary care dimension. RESULTS: Primary care services show considerable variation in user experiences. Users of the new (PSF) clinics reported higher overall assessments of the total primary care index and the sub-indices for gatekeeping, comprehensiveness, family focus and community orientation than did users of traditional services (P < 0.05). The total primary care score was internally consistent with a Cronbach's alpha of 0.8, and could be reduced to only one principal component. User assessments of primary care services were predicted by self-rated health (OR 1.72) and the site of care (OR 1.03). User and provider assessments of the total primary care index were not significantly different, disagreeing on only two sub-indices (gatekeeping and family focus, P < 0.05). CONCLUSIONS: The study presents a rapid and valid method of obtaining information about clinic-level variation in primary care organization and performance at district level. The total primary care index was not sensitive to demographic or socio-economic characteristics of clients, was internally consistent and appears valid given similar results obtained using two different data sources. With some adaptation the instrument could potentially be applied in other developing countries.     

Near-road air quality monitoring: Factors affecting network design and interpretation of data

The growing number of health studies identifying adverse health effects for populations spending significant amounts of time near large roadways has increased the interest in monitoring air quality in this microenvironment. Designing near-road air monitoring networks or interpreting previously collected near-road monitoring data is essential for transportation system planning, environmental impact assessments, and exposure assessments in health studies. For these applications, care must be taken in determining the pollutants of interest for both air quality and health assessments. In addition, planners and data analysts need to evaluate and understand the potential influence of the roadway type, design, and presence of roadside structures on the potential transport and dispersion of traffic-emitted pollutants on these air quality and health evaluations. This paper summarizes key factors related to the collection and interpretation of near-road air quality data from the perspective of the pollutants of interest and the location of the monitoring sites.     

Building health workforce capacity for planning and monitoring through the Strengthening Technical Assistance for routine immunization training (START) approach in Uganda

IntroductionThe Global Vaccine Action Plan identifies workforce capacity building as a key strategy to achieve strong immunization programs. The Strengthening Technical Assistance for Routine Immunization Training (START) approach aimed to utilize practical training methods to build capacity of district and health center staff to implement routine immunization (RI) planning and monitoring activities, as well as build supportive supervision skills of district staff.MethodsFirst implemented in Uganda, the START approach was executed by trained external consultants who used existing tools, resources, and experiences to mentor district-level counterparts and, with them, conducted on-the-job training and mentorship of health center staff over several site visits. Implementation was routinely monitored using daily activity reports, pre and post surveys of resources and systems at districts and health centers and interviews with START consultants.ResultsFrom July 2013 through December 2014 three START teams of four consultants per team, worked 6 months each across 50 districts in Uganda including the five divisions of Kampala district (45% of all districts). They conducted on-the-job training in 444 selected under-performing health centers, with a median of two visits to each (range 1–7, IQR: 1–3). More than half of these visits were conducted in collaboration with the district immunization officer, providing the opportunity for mentorship of district immunization officers. Changes in staff motivation and awareness of challenges; availability and completion of RI planning and monitoring tools and systems were observed. However, the START consultants felt that potential durability of these changes may be limited by contextual factors, including external accountability, availability of resources, and individual staff attitude.ConclusionsMentoring and on-the-job training offer promising alternatives to traditional classroom training and audit-focused supervision for building health workforce capacity. Further evidence regarding comparative effectiveness of these strategies and durability of observed positive change is needed.     

宁波市海曙区社区卫生服务现况分析

目的通过调查社区六项卫生服务落实情况,为政策制定提供依据.方法收集宁波市海曙区7个社区卫生服务中心和10个社区卫生服务站常规工作报告、报表及一周工作服务内容、服务量等资料,并进行统计分析.结果各社区六项卫生服务功能得到落实,按照服务量顺序,依次为医疗服务、健康教育、保健、预防、计划生育、康复.结论海曙区7个社区卫生服务中心六项卫生服务功能得到了全面体现,但各个社区之间发展不平衡,社区康复工作仍处于较低水平.     

Micro-level planning using rapid assessment for primary health care services

This paper describes the use of a rapid assessment technique in micro-level planning for primary health care services which has been developed in India. This methodology involves collecting household-level data through a quick sample survey to estimate client needs, coverage of services and unmet need, and using this data to formulate micro-level plans aimed at improving service coverage and quality for a primary health centre area. Analysis of the data helps to identify village level variations in unmet need and develop village profiles from which general interventions for overall improvement of service coverage and targeted interventions for selected villages are identified. A PHC area plan is developed based on such interventions. This system was tried out in 113 villages of three PHC centres of a district in Gujarat state of India. It demonstrated the feasibility and utility of this approach. However, it also revealed the barriers in the institutionalization of the system on a wider scale. The proposed micro-level planning methodology using rapid assessment would improve client-responsiveness of the health care system and provide a basis for increased decentralization. By focusing attention on under-served areas, it would promote equity in the use of health services. It would also help improve efficiency by making it possible to focus efforts on a small group of villages which account for most of the unmet need for services in an area. Thus the proposed methodology seems to be a feasible and an attractive alternative to the current top-down, target-based health planning in India.     

Development of a Person‐Centered Family Planning Scale in India and Kenya

Despite recognition that person‐centered care is a critical component to providing high quality family planning services, there lacks consensus on how to operationalize and measure it. This paper describes the development and validation of a person‐centered family planning (PCFP) scale in India and Kenya. Cross‐sectional data were collected from 522 women in Kenya and 225 women in India who visited a health facility providing family planning services. Psychometric analyses, including exploratory factor analysis, were employed to assess the validity and reliability of the PCFP scale. Separate scales were developed for India and Kenya due to context‐specific items. We assessed criterion validity by examining the association between PCFP and global measures of quality and satisfaction with family planning care. The analysis resulted in a multidimensional PCFP scale, including 20 items in Kenya and 22 items in India. Through iterative factor analysis, two subscales were identified for both countries: “autonomy, respectful care, and communication” and “health facility environment.” This scale may be used to evaluate quality improvement interventions and experiences of women globally to support women in achieving their reproductive health goals.     

Expanding access to primary care without additional budgets? A case study from Burkina Faso

The aim of this study is to demonstrate the impact of increased access to primary care on provider costs in the rural health district of Nouna, Burkina Faso. This study question is crucial for health care planning in this district, as other research work shows that the population has a higher need for health care services. From a public health perspective, an increase of utilisation of first-line health facilities would be necessary. However, the governmental budget that is needed to finance improved access was not known. The study is based on data of 2004 of a comprehensive provider cost information system. This database provides us with the actual costs of each primary health care facility (Centre de Santé et de Promotion Sociale, CSPS) in the health district. We determine the fixed and variable costs of each institution and calculate the average cost per service unit rendered in 2004. Based on the cost structure of each CSPS, we calculate the total costs if the demand for health care services increased. We conclude that the total provider costs of primary care (and therefore the governmental budget) would hardly rise if the coverage of the population were increased. This is mainly due to the fact that the highest variable costs are drugs, which are fully paid for by the customers (Bamako Initiative). The majority of other costs are fixed. Consequently, health care reforms that improve access to health care institutions must not fear dramatically increasing the costs of health care services. This study was supported by a research grant of the German Research Foundation (Deutsche Forschungsgemeinschaft).     

Assessment of Essential Newborn Care Services in Secondary-level Facilities from Two Districts of India

India faces a formidable burden of neonatal deaths, and quality newborn care is essential for reducing the high neonatal mortality rate. We examined newborn care services, with a focus on essential newborn care (ENC) in two districts, one each from two states in India. Nagaur district in Rajasthan and Chhatarpur district in Madhya Pradesh were included. Six secondary-level facilities from the districts─two district hospitals (DHs) and four community health centres (CHCs) were evaluated, where maximum institutional births within districts were taking place. The assessment included record review, facility observation, and competency assessment of service providers, using structured checklists and sets of questionnaire. The domains assessed for competency were: resuscitation, provision of warmth, breastfeeding, kangaroo mother care, and infection prevention. Our assessments showed that no inpatient care was being rendered at the CHCs while, at DHs, neonates with sepsis, asphyxia, and prematurity/low birthweight were managed. Newborn care corners existed within or adjacent to the labour room in all the facilities and were largely unutilized spaces in most of the facilities. Resuscitation bags and masks were available in four out of six facilities, with a predominant lack of masks of both sizes. Two CHCs in Chhatarpur did not have suction device. The average knowledge score amongst service providers in resuscitation was 76% and, in the remaining ENC domains, was 78%. The corresponding average skill scores were 24% and 34%, highlighting a huge contrast in knowledge and skill scores. This disparity was observed for all levels of providers assessed. While knowledge domain scores were largely satisfactory (>75%) for the majority of providers in domains of kangaroo mother care and breastfeeding, the scores were only moderately satisfactory (50-75%) for all other knowledge domains. The skill scores for all domains were predominantly non-satisfactory (<50%). The findings underpin the need for improving the existing ENC services by making newborn care corners functional and enhancing skills of service providers to reduce neonatal mortality rate in India.Key words: Clinical competence, Health facilities, Health personnel, Newborn care, Process assessment, India     

Cost analysis and efficiency of sub-district health facilities in two districts in Ghana

To establish the full costs borne by sub-district health facilities in providing services, we analysed the costs and revenues of 10 sub-district health facilities located in two districts in Ghana. The full costs were obtained by considering staff costs, cost of utilities, cost of using health facility equipment, cost of non-drug consumables, equipment maintenance expenses, amounts spent on training, community information sessions and other outreach activities as well as all other costs incurred in running the facilities. We found that (i) a large proportion of sub-district health facility costs is made up of staff salaries; (ii) at all facilities, internally generated funds (IGFs) are substantially lower than costs incurred in running the facilities; (iii) average IGF is several times higher in one district than the other; (iv) wide variations exist in efficiency indicators and (v) there is some evidence that sub-district health facilities may not necessarily be financially more efficient than hospitals in using financial resources. We suggest that the study should be replicated in other districts; but in the mean time, the health authorities should take note of the conclusions and recommendations of this study. Efforts should also be made to improve record keeping at these facilities.     

Capture-recapture analysis of all-cause mortality data in Bohol, Philippines

Background

Primary health care is recognized as a main driver of equitable health service delivery. For it to function optimally, routine health information systems (HIS) are necessary to ensure adequate provision of health care and the development of appropriate health policies. Concerns about the quality of routine administrative data have undermined their use in resource-limited settings. This evaluation was designed to describe the availability, reliability, and validity of a sample of primary health care HIS data from nine health facilities across three districts in Sofala Province, Mozambique. HIS data were also compared with results from large community-based surveys.

Methodology

We used a methodology similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria data verification bottom-up audit to assess primary health care HIS data availability and reliability. The quality of HIS data was validated by comparing three key indicators (antenatal care, institutional birth, and third diptheria, pertussis, and tetanus [DPT] immunization) with population-level surveys over time.

Results and discussion

The data concordance from facility clinical registries to monthly facility reports on five key indicators--the number of first antenatal care visits, institutional births, third DPT immunization, HIV testing, and outpatient consults--was good (80%). When two sites were excluded from the analysis, the concordance was markedly better (92%). Of monthly facility reports for immunization and maternity services, 98% were available in paper form at district health departments and 98% of immunization and maternity services monthly facility reports matched the Ministry of Health electronic database. Population-level health survey and HIS data were strongly correlated (R = 0.73), for institutional birth, first antenatal care visit, and third DPT immunization.

Conclusions

Our results suggest that in this setting, HIS data are both reliable and consistent, supporting their use in primary health care program monitoring and evaluation. Simple, rapid tools can be used to evaluate routine data and facilitate the rapid identification of problem areas.     

Accuracy of Standard Measures of Family Planning Service Quality: Findings from the Simulated Client Method

In the field of international family planning, quality of care as a reproductive right is widely endorsed, yet we lack validated data‐collection instruments that can accurately assess quality in terms of its public health importance. This study, conducted within 19 public and private facilities in Kisumu, Kenya, used the simulated client method to test the validity of three standard data‐collection instruments used in large‐scale facility surveys: provider interviews, client interviews, and observation of client–provider interactions. Results found low specificity and low positive predictive values in each of the three instruments for a number of quality indicators, suggesting that the quality of care provided may be overestimated by traditional methods of measurement. Revised approaches to measuring family planning service quality may be needed to ensure accurate assessment of programs and to better inform quality‐improvement interventions.     

Understanding the gap between need and utilization in outpatient care—The effect of supply-side determinants on regional inequities

The present study analyzes the effect of supply-side determinants on regional inequities in outpatient care. Inequities are measured by the degree of disparity between need for and actual utilization of outpatient health services in the 412 German districts. Outpatient care needs of each district are determined by applying the regression model of the German risk structure compensation scheme. We find that supply-side factors account for half of the model's coverage of regional inequities. The remaining regional variance explained by the model may be attributed to socioeconomic and (socio-)geographic determinants as well as price effects. Our findings call for strengthening the role of GPs as coordinators in the health care system, countering the geographic maldistribution of physicians and introducing adequate programs to improve the level of care in socially deprived districts. The study also highlights the importance of differentiating between need, demand and utilization of health services in order to understand the root causes of inequities.     

Community and facility-level engagement in planning and budgeting for the government health sector--a district perspective from Kenya

Health systems reform processes have increasingly recognized the essential contribution of communities to the success of health programs and development activities in general. Here we examine the experience from Kilifi district in Kenya of implementing annual health sector planning guidelines that included community participation in problem identification, priority setting, and planning. We describe challenges in the implementation of national planning guidelines, how these were met, and how they influenced final plans and budgets. The broad-based community engagement envisaged in the guidelines did not take place due to the delay in roll out of the Ministry of Health-trained community health workers. Instead, community engagement was conducted through facility management committees, though in a minority of facilities, even such committees were not involved. Some overlap was found in the priorities highlighted by facility staff, committee members and national indicators, but there were also many additional issues raised by committee members and not by other groups. The engagement of the community through committees influenced target and priority setting, but the emphasis on national health indicators left many local priorities unaddressed by the final work plans. Moreover, it appears that the final impact on budgets allocated at district and facility level was limited. The experience in Kilifi highlights the feasibility of engaging the community in the health planning process, and the challenges of ensuring that this engagement feeds into consolidated plans and future implementation.     

User satisfaction is influenced by the interval between a health care service and the assessment of the service

In order to improve the quality of patient care, questionnaires are often used to identify user’s experiences and evaluations, but only a few studies have examined whether measuring user satisfaction at different time points influences the assessment of health care. Several studies have shown equivalency between paper and electronic patient reported outcomes; however, none of these studies have considered the fact that electronic questionnaires are usually completed at the hospital, while paper questionnaires are typically completed at home weeks after the visit. In order to ensure that the comparison of results collected by the two different methods are not biased, the aim of this study was to determine if the interval between an outpatient visit and the assessment of the quality of care influences user satisfaction and to compare response rates between questionnaires completed at different times. In a follow-up study, parents from a paediatric outpatient clinic in Denmark were quasi-randomised to 1 of 3 groups: group 1 completed an electronic questionnaire on a touch screen computer in the outpatient clinic and a paper questionnaire 3–6 weeks after the visit; group 2 completed a paper questionnaire in the outpatient clinic and a paper questionnaire 3–6 weeks after the visit; and group 3 completed a paper questionnaire 3–6 weeks after the visit. A total of 1148 parents completed at least 1 questionnaire. User satisfaction was significantly lower when the assessment was made after a visit to the outpatient clinic compared to an assessment made at the clinic. The response rates of questionnaires completed at the clinic were significantly higher than the response rates of questionnaires completed after the visit. Both the timing of surveys and response rates need to be taken into consideration when planning user surveys. Outcomes from surveys conducted at different times are not readily comparable.     

Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania

Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in‐depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health‐governing committees.     

苏北农村地区结核病患者首诊机构选择和配置研究

目的：比较农村结核病控制项目地区和非项目地区病人对首诊机构的选择，和首诊机构在结核病诊断和转诊中存在的问题。方法：对苏北结核病控制项目县（建湖县）和非项目县（阜宁县）2002年全年登记的493名新诊断结核病人进行问卷调查。结果：首次就诊直接去县结防所的痛人比例仅为1％左右．首次就诊比例最高的机构为村诊所。项目县县市级医院和乡镇医院获得转诊的比例显著高于非项目县。结论：应着力于促使乡镇医院和县市医院及早对病人进行相应检查和及时转诊，完善转诊管理体系。     

Principles of health infrastructure planning in less developed countries

This article proposes a number of key principles for health infrastructure planning, based on a literature review on the one hand, and on a process of internal deduction on the other. The principles discussed are the following: an integrated health system; a thrifty planning of tiers within that health system; a specificity of tiers; a homogeneity of the tiers' structures; a minimum package of activities; a territorial responsibility and/or an explicit and discrete responsibility for a well-defined population; a necessary and sufficient population basis; a partial separation of administrative and public health planning bases; and, finally, rules for a geographical division and integration of non-governmental organizations. The definition of two strategies, primary health care and district health systems, is also revisited.     

French Cross-Cultural Adaptation of the Health Utilities Indexes Mark 2 (HUI2) and 3 (HUI3) Classification Systems

The McMaster Health Utilities Indexes Mark 2 (HUI2) and 3 (HUI3) are multiattribute health classification systems, for which multiattribute preference functions have been developed in Canada. They provide a comprehensive instrument for use in economic evaluations and population health survey studies. This paper reports on the first results on the adaptation of the HUI2 and HUI3 systems cross-culturally and the assessment of the validity and reliability of the French self-report questionnaire in different patient populations. The cross-cultural adaptation included translation, backtranslations, an expert consensus meeting and pre-test with a few patients and healthy subjects in order to produce a conceptually equivalent French version of the 15 question self-report questionnaire and the HUI2 and HUI3 classification systems. Different groups of patients attending specialized clinics (n = 709) completed the questionnaire and another generic questionnaire (the Sickness Impact Profile (SIP)) for validity assessment. Physicians and patients were also asked for a global subjective assessment of the patient's health status. The French questionnaire was well received by the patients. The criterion and convergent validities of both classification systems (correlations with the patients' and physicians' assessments and with the responses to the SIP questionnaire) were satisfactory. The internal consistency was acceptable too (Cronbach's α = 0.81), as was the 3 day test-retest reproducibility. These first results authorize careful use of the 15 question self-report questionnaire in French. An assessment of the multiattribute preference function for the HUI3 system in France will be the study's next objective. This revised version was published online in June 2006 with corrections to the Cover Date.     

The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania

Integrated Management of Childhood Illness (IMCI) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development. It includes complementary interventions designed to address the major causes of child mortality at community, health facility, and health system levels. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (IMCI-MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization. MCE studies are under way in Bangladesh, Brazil, Peru, Tanzania and Uganda. In Tanzania, the IMCI-MCE study uses a non-randomized observational design comparing four neighbouring districts, two of which have been implementing IMCI in conjunction with evidence-based planning and expenditure mapping at district level since 1997, and two of which began IMCI implementation in 2002. In these four districts, child health and child survival are documented at household level through cross-sectional, before-and-after surveys and through longitudinal demographic surveillance respectively. Here we present results of a survey conducted in August 2000 in stratified random samples of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts. The results indicate that children in IMCI districts received better care than children in comparison districts: their health problems were more thoroughly assessed, they were more likely to be diagnosed and treated correctly as determined through a gold-standard re-examination, and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children. There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. This study suggests that IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource-poor countries and can lead to rapid gains in the quality of case-management. IMCI is therefore likely to lead to rapid gains in child survival, health and development if adequate coverage levels can be achieved and maintained.