Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania’s Health System

IntroductionPeople in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system.MethodsUsing mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child’s respiratory symptoms.ConclusionADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.     

武汉市公立医院药品价格水平实证研究

目的 了解武汉市公立医院的药品相对价格水平,揭示药品市场现存的问题。方法 选择全国市场销售排名前100位的药品全部纳入研究样本,收集武汉市12家公立医院和14家零售药房的药品价格数据,对定量资料进行统计分析,对公立医院间及其与零售药房间的药品价格进行差异性比较。结果 公立医院的药品均价高于零售药房同商品名药品的均价;公立医院间同商品名的药品均价差异不显著,但同通用名的药品价格差异有较大的波动性。结论 进一步建立健全药品监管制度,加快削弱公立医院的垄断地位,严格药品招标采购管理,建立健全国家基本药物制度。     

我国二级及以上医疗机构开展公共卫生工作现况分析

目的 对二级以上医疗机构疾病预防控制等公共卫生工作现况进行评估。方法 对全国10个省163家医院进行二级以上医疗机构公共卫生工作开展基本情况调查和人员基本情况调查的问卷调查;对全国34个省、自治区、直辖市和新疆生产建设兵团进行函调以及对浙江、河南、辽宁和甘肃4个省进行实地调研。结果（1）医疗机构应承担的公共卫生职能与落实情况相差甚远。（2）医疗机构从事公共卫生工作积极性不高。（3）医疗机构在公共卫生工作中接受多个部门管理,但在工作中缺乏协调。结论（1）弥合临床医疗服务体系与公共卫生体系的割裂状态。（2）增强医疗机构从事公共卫生工作积极性。（3）加强督察考核,促进公共卫生工作的落实。     

Presumptive Treatment of Malaria from Formal and Informal Drug Vendors in Nigeria

Background

Despite policies that recommend parasitological testing before treatment for malaria, presumptive treatment remains widespread in Nigeria. The majority of Nigerians obtain antimalarial drugs from two types of for-profit drug vendors—formal and informal medicine shops—but little is known about the quality of malaria care services provided at these shops.

Aims

This study seeks to (1) describe the profile of patients who seek treatment at different types of drug outlets, (2) document the types of drugs purchased for treating malaria, (3) assess which patients are purchasing recommended drugs, and (4) estimate the extent of malaria over-treatment.

Methods

In urban, peri-urban, and rural areas in Oyo State, customers exiting proprietary and patent medicine vendor (PPMV) shops or pharmacies having purchased anti-malarial drugs were surveyed and tested with malaria rapid diagnostic test. A follow-up phone survey was conducted four days after to assess self-reported drug administration. Bivariate and multivariate regression analysis was conducted to determine the correlates of patronizing a PPMV versus pharmacy, and the likelihood of purchasing an artemisinin-combination therapy (ACT) drug.

Results

Of the 457participants who sought malaria treatment in 49 enrolled outlets, nearly 92% had diagnosed their condition by themselves, a family member, or a friend. Nearly 60% pharmacy customers purchased an ACT compared to only 29% of PPMV customers, and pharmacy customers paid significantly more on average. Multivariate regression results show that patrons of PPMVs were younger, less wealthy, waited fewer days before seeking care, and were less likely to be diagnosed at a hospital, clinic, or laboratory. Only 3.9% of participants tested positive with a malaria rapid diagnostic test.

Conclusions

Poorer individuals seeking care at PPMVs are more likely to receive inappropriate malaria treatment when compared to those who go to pharmacies. Increasing accessibility to reliable diagnosis should be explored to reduce malaria over-treatment.     

Web-Based Training for Primary Healthcare Workers in Rural China: A Qualitative Exploration of Stakeholders’ Perceptions

BackgroundEquitable access to basic public health services is a priority in China. However, primary healthcare workers’ competence to deliver public health services is relatively poor because they lack professional training. Since the availability of web-based training has increased in China, the current study explored stakeholders’ perceptions of a web-based training program on basic public health services to understand their thoughts, experiences, and attitudes about it.MethodsSix focus group discussions with primary healthcare workers and three with directors of township hospitals, county-level Health Bureaus, and county-level Centers for Disease Control and Prevention were conducted in Yichang City during 2013. Semi-structured topic guides were used to facilitate qualitative data collection. Audio recordings of the sessions were transcribed verbatim and theme analysis was performed.ResultsMost of the study’s participants, especially the village doctors, had insufficient knowledge of basic public health services. The existing training program for primary healthcare workers consisted of ineffective traditional face-to-face sessions and often posed accessibility problems for the trainees. Most of the study’s participants had a positive attitude about web-based learning and expressed a strong desire to receive this novel training approach because of its flexibility and convenience. The perceived barriers to utilizing the web-based training method included poor computer literacy, lack of personal interaction, inadequate infrastructure, and lack of time and motivation. The facilitators of this approach included the training content applicability, the user-friendly and interactive learning format, and policy support.ConclusionsWeb-based training on basic public health services is a promising option in rural China. The findings of the study will contribute knowledge to implementation of web-based training in similar settings.     

Experience on healthcare utilization in seven administrative regions of Tanzania

Health care utilization in many developing countries, Tanzania included, is mainly through the use of traditional medicine (TRM) and its practitioners despite the presence of the conventional medicine. This article presents findings on the study that aimed to get an experience of health care utilization from both urban and rural areas of seven administrative regions in Tanzania. A total of 33 health facility managers were interviewed on health care provision and availability of supplies including drugs, in their respective areas. The findings revealed that the health facilities were overburden with higher population to serve than it was planned. Consequently essential drugs and other health supplies were available only in the first two weeks of the month. Conventional health practitioners considered traditional health practitioners to be more competent in mental health management, and overall, they were considered to handle more HIV/AIDS cases knowingly or unknowingly due to shear need of healthcare by this group. In general conventional health practitioners were positive towards traditional medicine utilization; and some of them admitted using traditional medicines. Traditional medicines like other medical health systems worldwide have side effects and some contentious ethical issues that need serious consideration and policy direction. Since many people will continue using traditional/alternative medicine, there is an urgent need to collaborate with traditional/alternative health practitioners through the institutionalization of basic training including hygiene in order to improved healthcare in the community and attain the Millennium Development Goals by 2015.     

Availability,affordability and stock-outs of commodities for the treatment of snakebite in Kenya

BackgroundAnnually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya.Methodology/principal findingsThis study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day’s wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days’ wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible.ConclusionsAccess to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.     

Measuring Access to Medicines: A Survey of Prices,Availability and Affordability in Shaanxi Province of China

Objective

To measure the prices and availability of selected medicines in Shaanxi Province after the implementation of new healthcare reform in 2009.

Methods

Data on the prices and availability of 47 medicines were collected from 50 public and 36 private sector medicine outlets in six regions of Shaanxi Province, Western China using a standardized methodology developed by the World Health Organization and Health Action International from September to October 2010. Medicine prices were compared with international reference prices to obtain a median price ratio. Affordability was measured as the number of days’ wages required for the lowest-paid unskilled government worker to purchase standard treatments for common conditions.

Findings

The mean availabilities of originator brands and lowest-priced generics were 8.9% and 26.5% in the public sector, and 18.1% and 43.6% in the private sector, respectively. The public sector procured generics and originator brands at median price ratios of 0.75 and 8.49, respectively, while patients paid 0.97 and 10.16. Final patient prices for lowest-priced generics and originator brands in the private sector were about 1.53 and 8.36 times their international retail prices, respectively. Public sector vendors applied high markups of 30.4% to generics, and 19.6% to originator brands. In the private sector, originator brands cost 390.7% more, on average, than their generic equivalents. Generic medicines were priced 17.3% higher in the private sector than the public sector. The lowest-paid government worker would need 0.1 day’s wages to purchase captopril for lowest-priced generics from private sector, while 6.6 days’ wages for losartan. For originator brands, the costs rise to 1.2 days’ wages for salbutamol inhaler and 15.6 days’ wages for omeprazole.

Conclusions

The prices, availability and affordability of medicines in China should be improved to ensure equitable access to basic medical treatments, especially for the poor. This requires multi-faceted interventions, as well as the review and refocusing of policies, regulations and educational interventions.     

Affordability of commonly prescribed antibiotics in a large tertiary teaching hospital in Ethiopia: a challenge for the national drug policy objective

Objective

In national drug policies of many countries, ensuring availability and affordability of essential medicines is indicated among the major policy objectives. To achieve the objectives, countries with low and middle income compile such medicines into NEMLs. This study aims to determine availability and affordability of commonly prescribed antibiotics at a tertiary hospital in Ethiopia by assessing (in private and public pharmacies) 13 antibiotics constituting DU90% at the hospital.

Results

Availability of the antibiotics in the private and public pharmacies was 92.3% and 98.5%, respectively. Average MPRs for the antibiotics were 4.1 and 2.7, respectively, in the private and public pharmacies. The days’ wages (in median prices) ranged from 0.2 for treating acute diarrhea with doxycycline to 415.8 for treating HAP in public pharmacies. Costs of a single day treatment with antibiotics purchased from the public pharmacies ranged from USD 0.1 for acute diarrhea to USD 29.7 for HAP. For the private pharmacies, the range was from USD 0.1 for toxoplasmosis to USD 54.9 for HAP. This study showed that treatments of commonly diagnosed infectious conditions at TASH remain unaffordable according to the WHO/HAI criteria.

     

Addressing antimicrobial resistance by improving access and quality of care—A review of the literature from East Africa

Universal access to healthcare, including quality medicines, is a fundamental human right but is still out of reach for many in low- and middle-income countries (LMICs). An existing framework capturing variability of access to healthcare in low-resource settings includes the 5 dimensions: availability, accessibility, affordability, adequacy, and acceptability. This framework encompasses key components, including health infrastructure and means to access it as well as service organisation, costs, and factors that influence users’ satisfaction. However, in reality, the effectiveness of accessed healthcare is measured by the likelihood of a positive outcome. We therefore propose an expansion of this framework to include an additional dimension, “aspects of quality,” incorporating quality, which critically influences the ability of the accessed services to generate optimal health outcomes. Within this framework, we explore literature from East Africa likely relevant to a range of LMIC contexts, mainly focusing on the provision of widely used antimicrobials such as antimalarials and antibiotics. We argue that major inadequacies exist across all 6 dimensions of access and quality of drugs and their provision. While the global focus is on curbing excessive antimicrobial use to tackle the antimicrobial resistance (AMR) crisis, major constraints around access shape patients’ health-seeking decisions leading to potentially problematic practices that might exacerbate the AMR problem. We advocate for a holistic approach to tackling these inadequacies, encompassing all dimensions of access and quality of healthcare in order to improve health outcomes while simultaneously counteracting the AMR crisis.     

Improving timeliness in the neglected tropical diseases preventive chemotherapy donation supply chain through information sharing: A retrospective empirical analysis

BackgroundBillions of doses of medicines are donated for mass drug administrations in support of the World Health Organization’s “Roadmap to Implementation,” which aims to control, eliminate, and eradicate Neglected Tropical Diseases (NTDs). The supply chain to deliver these medicines is complex, with fragmented data systems and limited visibility on performance. This study empirically evaluates the impact of an online supply chain performance measurement system, “NTDeliver,” providing understanding of the value of information sharing towards the success of global health programs.MethodsRetrospective secondary data were extracted from NTDeliver, which included 1,484 shipments for four critical medicines ordered by over 100 countries between February 28, 2006 and December 31, 2018. We applied statistical regression models to analyze the impact on key performance metrics, comparing data before and after the system was implemented.FindingsThe results suggest information sharing has a positive association with improvement for two key performance indicators: purchase order timeliness (β = 0.941, p = 0.003) and—most importantly—delivery timeliness (β = 0.828, p = 0.027). There is a positive association with improvement for three variables when the data are publicly shared: shipment timeliness (β = 2.57, p = 0.001), arrival timeliness (β = 2.88, p = 0.003), and delivery timeliness (β = 2.82, p = 0.011).ConclusionsOur findings suggest that information sharing between the NTD program partners via the NTDeliver system has a positive association with supply chain performance improvements, especially when data are shared publicly. Given the large volume of medicine and the significant number of people requiring these medicines, information sharing has the potential to provide improvements to global health programs affecting the health of tens to hundreds of millions of people.     

Managing Minor Ailments; The Public’s Preferences for Attributes of Community Pharmacies. A Discrete Choice Experiment

Background

Demand for health services continues to rise. Greater use of community pharmacy services instead of medical services for minor ailments could help relieve pressure on healthcare providers in high-cost settings. Community pharmacies are recognised sources of treatment and advice for people wishing to manage these ailments. However, increasing the public’s use of pharmacy services may depend on attributes of pharmacies and their staff. This study aimed to determine the general public’s relative preferences for community pharmacy attributes using a discrete choice experiment (DCE).

Method

A UK-wide DCE survey of the general public was conducted using face-to-face computer-assisted personal interviews. Attributes and levels for the DCE were informed by a literature review and a cohort study of community pharmacy customers. The context for the experiment was a minor ailment scenario describing flu-like symptoms. The DCE choice sets described two hypothetical community pharmacy services; respondents were asked to choose which (if either) of the two pharmacies they would prefer to help them manage symptoms. Data from 1,049 interviews were analysed using an error components logit model. Willingness to pay (WTP), a monetary measure of benefit, was estimated for the different attribute levels.

Results

When seeking help or treatment for flu-like symptoms, respondents most valued a pharmacy service that would improve their understanding and management of symptoms (WTP = £6.28), provided by staff who are trained (WTP (pharmacist) = £2.63: WTP(trained assistant) = £3.22), friendly and approachable (WTP = £3.38). Waiting time, pharmacy location and availability of parking also contributed to respondents’ preferences. WTP for a service comprising the best possible combination of attributes and levels was calculated as £55.43.

Conclusion

Attributes of a community pharmacy and its staff may influence people’s decisions about which pharmacy they would visit to access treatment and advice for minor ailments. In line with the public’s preferences, offering community pharmacy services that help people to better understand and manage symptoms, are provided promptly by trained staff who are friendly and approachable, and in a local setting with easy access to parking, has the potential to increase uptake amongst those seeking help to manage minor ailments. In this way it may be possible to shift demand away from high-cost health services and make more efficient use of scarce public resources.     

Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial

BackgroundAdherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted.Methods and findingsWe randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI −0.25 to 0.79, p = 0.302), systolic blood pressure (−3.9; 95% CI −9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI −0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports.ConclusionsIn this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years.Trial registrationClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT02744963","term_id":"NCT02744963"}}NCT02744963.     

Examining the Ugandan health system’s readiness to deliver rheumatic heart disease-related services

BackgroundIn 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda.Methodology/Principal findingsThis was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare.Conclusions/SignificanceUganda’s readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.     

Injections,Cocktails and Diviners: Therapeutic Flexibility in the Context of Malaria Elimination and Drug Resistance in Northeast Cambodia

Background

Adherence to effective malaria medication is extremely important in the context of Cambodia’s elimination targets and drug resistance containment. Although the public sector health facilities are accessible to the local ethnic minorities of Ratanakiri province (Northeast Cambodia), their illness itineraries often lead them to private pharmacies selling “cocktails” and artemether injections, or to local diviners prescribing animal sacrifices to appease the spirits.

Methods

The research design consisted of a mixed methods study, combining qualitative (in-depth interviews and participant observation) and quantitative methods (household and cross-sectional survey).

Results

Three broad options for malaria treatment were identified: i) the public sector; ii) the private sector; iii) traditional treatment based on divination and ceremonial sacrifice. Treatment choice was influenced by the availability of treatment and provider, perceived side effects and efficacy of treatments, perceived etiology of symptoms, and patient-health provider encounters. Moreover, treatment paths proved to be highly flexible, changing mostly in relation to the perceived efficacy of a chosen treatment.

Conclusions

Despite good availability of anti-malarial treatment in the public health sector, attendance remained low due to both structural and human behavioral factors. The common use and under-dosage of anti-malaria monotherapy in the private sector (single-dose injections, single-day drug cocktails) represents a threat not only for individual case management, but also for the regional plan of drug resistance containment and malaria elimination.     

Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis

BackgroundUniversal health coverage (UHC) encompasses 2 main components: access to essential healthcare services and protection from financial hardship when using healthcare. This study examines Myanmar’s efforts to achieve UHC on a national and subnational level. It is a primer of studying the concept of UHC on a subnational level, and it also establishes a baseline for assessing future progress toward reaching UHC in Myanmar.Methods and findingsThe study uses the Demographic and Health Survey (2015) and the Myanmar Living Conditions Survey (MLCS; 2017) and adapts a previously developed UHC index to provide insights into the main barriers preventing the country’s progress toward UHC. We find a negative correlation between the UHC index and the state/region poverty levels. The equity of access analysis reveals significant pro-rich inequity in access to all essential healthcare services. Socioeconomic status and limited availability of healthcare infrastructure are the main driving forces behind the unequal access to interventions that are crucial to achieving UHC by 2030. Finally, financial risk protection analysis shows that the poor are less likely to use healthcare services, and, once they do, they are at a greater risk of suffering financial catastrophe. Limitations of this study revolve around its correlational, rather than causal, nature.ConclusionsWe suggest a 2-pronged approach to help Myanmar achieve UHC: Government and state authorities should reduce the financial burden of seeking healthcare, and, coupled with this, significant investment in and expansion of health infrastructure and the health workforce should be made, particularly in the poorer and more remote states.

Zlatko Nikoloski and colleagues provide analytical insight into Myanmar’s efforts to achieve universal health coverage on a national and sub-national level.     

The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone

Background

As Sierra Leone celebrates the end of the Ebola Virus Disease (EVD) outbreak, we can begin to fully grasp its impact on already weak health systems. The EVD outbreak in West Africa forced many hospitals to close down or reduce their activity, either to prevent nosocomial transmission or because of staff shortages. The aim of this study is to assess the potential impact of EVD on nationwide access to obstetric care in Sierra Leone.

Methods and Findings

Community health officers collected weekly data between January 2014—May 2015 on in-hospital deliveries and caesarean sections (C-sections) from all open facilities (public, private for-profit and private non-profit sectors) offering emergency obstetrics in Sierra Leone. This was compared to official data of EVD cases per district. Logistic and Poisson regression analyses were used to compute risk and rate estimates. Nationwide, the number of in-hospital deliveries and C-sections decreased by over 20% during the EVD outbreak. The decline occurred early on in the EVD outbreak and was mainly attributable to the closing of private not-for-profit hospitals rather than government facilities. Due to difficulties in collecting data in the midst of an epidemic, limitations of this study include some missing data points.

Conclusions

Both the number of in-hospital deliveries and C-sections substantially declined shortly after the onset of the EVD outbreak. Since access to emergency obstetric care, like C-sections, is associated with decreased maternal mortality, many women are likely to have died due to the reduced access to appropriate care during childbirth. Future research on indirect health effects of health system breakdown should ideally be nationwide and continue also into the recovery phase. It is also important to understand the mechanisms behind the deterioration so that important health services can be reestablished.     

Comparison of Perceived and Technical Healthcare Quality in Primary Health Facilities: Implications for a Sustainable National Health Insurance Scheme in Ghana

Background

Quality care in health facilities is critical for a sustainable health insurance system because of its influence on clients’ decisions to participate in health insurance and utilize health services. Exploration of the different dimensions of healthcare quality and their associations will help determine more effective quality improvement interventions and health insurance sustainability strategies, especially in resource constrained countries in Africa where universal access to good quality care remains a challenge.

Purpose

To examine the differences in perceptions of clients and health staff on quality healthcare and determine if these perceptions are associated with technical quality proxies in health facilities. Implications of the findings for a sustainable National Health Insurance Scheme (NHIS) in Ghana are also discussed.

Methods

This is a cross-sectional study in two southern regions in Ghana involving 64 primary health facilities: 1,903 households and 324 health staff. Data collection lasted from March to June, 2012. A Wilcoxon-Mann-Whitney test was performed to determine differences in client and health staff perceptions of quality healthcare. Spearman’s rank correlation test was used to ascertain associations between perceived and technical quality care proxies in health facilities, and ordered logistic regression employed to predict the determinants of client and staff-perceived quality healthcare.

Results

Negative association was found between technical quality and client-perceived quality care (coef. = -0.0991, p<0.0001). Significant staff-client perception differences were found in all healthcare quality proxies, suggesting some level of unbalanced commitment to quality improvement and potential information asymmetry between clients and service providers. Overall, the findings suggest that increased efforts towards technical quality care alone will not necessarily translate into better client-perceived quality care and willingness to utilize health services in NHIS-accredited health facilities.

Conclusion

There is the need to intensify client education and balanced commitment to technical and perceived quality improvement efforts. This will help enhance client confidence in Ghana’s healthcare system, stimulate active participation in the national health insurance, increase healthcare utilization and ultimately improve public health outcomes.