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Assessing the quality of health care and in particular the part it plays in performance assessment of individuals, institutions and health systems is a topic of increasing interest in high-income settings Elwyn et al. What of low-income nations? Is it relevant to be concerned about quality? How might perspectives differ and are there some clear priorities? Our experience lies in the arena of child and newborn health in Kenya and it is from this vantage point we offer some thoughts. We do this with a hope of increasing awareness of, and debate around, quality and performance as major issues at country level in low-income settings.
At international levels quality and performance concerns reflect, among others, the global issues related to coverage of services Bryce et al. Areas in which the problems encountered in low-income settings make those of high-income countries appear inconsequential.
However, these debates concentrate on cross-country comparisons or provide headline figures on global or regional problems. There is very little discussion, however, of quality and performance within a country's health system. We would like to adopt this perspective and suggest that country-level requirements have yet to receive the attention they deserve. Does quality worry anyone?
Understandably considerable investments are being made in improving coverage of and hence access to services. However, as coverage improves it is increasingly apparent that anticipated benefits will only be realized if services are of high quality. In Kenya quality is a major stated concern of the government and this prompted development of the Kenya Quality Model Government of Kenya However, operationalizing this model remains difficult.
As regards child and newborn health care, WHO have helped lead a still small but slowly growing interest in quality, at least from the perspective of small hospitals Campbell et al. However, these two laudable initiatives have limitations. The former provides an excellent opportunity for identifying key concerns and initiating debate and action, but it is not a measurement tool. The latter is a five-yearly situation analysis largely concentrating on structural components of quality.
What more would we like to know? In the traditional Donabedian approach, outcomes of the healthcare process are intuitively the most important if not the easiest to interpret. However, outcomes of value from the health systems perspective are varied, ranging from the fundamental, i. How well equipped are low-income countries to assess such outcomes?
Unfortunately the answer is: not well equipped at all. Routine health management information systems HMIS rarely provide reliable information even on such basic indicators as the number of patients seen Gething et al. In-hospital number of deaths and case fatality rates are rarely known accurately at facility level, let alone regional or national level. Information on surgical complication rates, nosocomial infection rates, frequency of medical errors or other potentially important medical outcomes is not available.
From a more managerial perspective, interest in clinic attendance rates and frequency of provision of medical, surgical or diagnostic procedures is largely restricted to their ability to generate local income through cost recovery. Using such data to inform local or national quality of care debates is rare.
Understanding the performance of a particular set of clinical workers within a facility or of a facility itself is rarely possible. The views of health system users are also an increasingly important outcome in judging the quality of healthcare provision in developed country settings. Are these views, felt, heard or acted upon in low-income settings? In the new healthcare quasi- markets of many industrialized countries, patient choice is, in theory, an indication of preference and thus a reflection of quality.
The possibilities for choice in low-income countries are probably more varied than many imagine. In urban areas there has been a rapid and, some would say, largely unregulated expansion of the private sector. Larger, better-equipped facilities compete for the relatively small but financially important higher income groups who for many years have opted out of public healthcare systems. However, the greatest expansion has been in small, even single-provider, private clinics Noor et al.
Those belonging to the lower income groups prefer private clinics, because people have the general perception that the public sector performs poorly Boller et al. However, satisfaction has been a topic of a reasonable body of research.
It is hard to summarize this work succinctly and accurately, but it is clear that users in low-income settings are highly sensitive to quality issues. Absence of resources, inconvenient opening times, poor infrastructure, and staff attitudes and behaviour are all reported to be important aspects of quality even in poor, rural areas Newman et al.
Assessment of structural attributes of quality seems to be of little concern in many high-income settings — a basic and high standard of resource availability is usually assumed. Such assumptions would obviously be perilous in low-income settings. Lack of resources means that such data are often collected from samples of the health system to indicate the average level of provision. But while initially useful, the real need is to know, in every case, who does not have what.
Indicators are often crude also. While activities such as essential drug-monitoring programmes initiated by the WHO and other efforts are slowly establishing standards for basic resource provision and evaluating systems on this basis, we are far from knowing what resources are available and where.
If the resources are available then achieving a worthwhile outcome depends on what we do as health workers — what we offer as a process of care. We will touch here on only a few issues pertinent to assessing the quality of the process of care limiting ourselves to clinical concerns. This ignores huge areas where quality is often poor, for example in the organization of services, respect for patient dignity or autonomy or rights of complaint, accountability or redress.
Thinking about quality is, in our experience, often so alien to providers that they do not even realize that these topics and others are their concern. Potentially as damaging, however, is the situation in which providers and patients assume that the quality of care is adequate when in fact what is being offered is technically incorrect and occasionally dangerous.
For this reason, technical competence should retain a central concern in debates over the quality of care in low-income settings. In developed countries huge numbers of standards, guidelines and practice recommendations, based on evidence, define technical competence.
Quality assessment and improvement activities in these countries often revolve around evaluating the extent to which practitioners follow this guidance, the degree of adherence being a major element in performance assessment. The WHO and others have developed and, with national governments, formally disseminated technical guidelines covering many areas of essential healthcare practice. However, these guidelines often do not reach practitioners, supervisors or even training institutions.
The result is that much basic practice is technically substandard even when resources are not limiting. The development of indicators for monitoring is in itself a science.
Unfortunately it is a science that is largely undiscovered within public health systems in developing countries. Even if developed, the capacity for routine data collection, synthesis and analysis based on such indicators is often rudimentary.
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