Landscape of team-based care to manage hypertension: results from two surveys in low/middle-income countries.

OBJECTIVES: Team-based care is essential for improving hypertension outcomes in low-resource settings. We assessed perceptions of country representatives and healthcare workers (HCWs) on team-based hypertension care in low/middle-income countries. DESIGN: Two cross-sectional surveys. SETTING: The first survey (Country Profile Survey) was conducted in 17 countries and eight in-country regions: Algeria, Bangladesh, Burundi, Chile, China (Beijing, Henan, Shandong), Cuba, Ethiopia, India (Kerala, Madhya Pradesh, Maharashtra, Punjab, Telangana), Nepal, Nigeria, Philippines, Saint Lucia, Sri Lanka, Thailand, Turkey, Uganda and Vietnam. The second survey (HCW Survey) was conducted in four countries: Bangladesh, China, Ethiopia and Nigeria. PARTICIPANTS: Using convenience sampling, participants for the Country Profile Survey were representatives from 17 countries and eight in-country regions, and the HCW Survey was administered to HCWs in Bangladesh, China, Ethiopia and Nigeria. OUTCOME MEASURES: Country-level use of team-based hypertension care framework, comprising administrative, basic and advanced clinical tasks. Current practices of different HCW cadres, perspectives on team-based management of hypertension, barriers and facilitators. RESULTS: In the Country Profile Survey, all (23/23, 100%) countries/regions surveyed integrated team-based care for basic clinical hypertension management tasks, less for advanced tasks (7/23, 30%). In the HCW Survey, 854 HCWs participated, 47% of whom worked in rural settings. Most HCWs in the sample acknowledged the value of team-based hypertension care. Although there were slight variations by country in the study sample, overall, barriers to team-based hypertension care were identified as inadequate training (83%); regulatory issues (76%); resistance by patients (56%), physicians (42%) and nurses (40%). Facilitators identified were use of treatment algorithms (94%), telehealth/m-health technology (92%) and adequate compensation for HCWs (80%). CONCLUSIONS: Our findings revealed key lessons for health systems and governments regarding team-based care implementation. Specifically, policies to facilitate additional training, optimise HCWs' roles within care teams, use of hypertension treatment protocols and telehealth/m-health technology will be essential to promote team-based care.

Self-paced online learning to improve knowledge competencies for hypertension among medical students in Uganda: A pre-post study.

The growing burden of hypertension (HT) is projected to reach 1.56 billion globally by 2025 and is an increasing public health concern, even for low- and middle-income countries (LMIC) like Uganda, where the prevalence of HT is 31.5%. The objective of this study was to test the effectiveness of a freely available HT online course on knowledge competencies for medical students in Uganda. The online course was developed by a multidisciplinary team at Johns Hopkins University to address HT control in resource-constrained healthcare settings. Students in the 3rd, 4th, and 5th years of medical school were randomly selected to participate in the online course. Pre and post knowledge tests were administered using an online survey system. Of the 201 invited students, 121 (60.2%) completed the study. Significant improvements in mean knowledge scores were evident following the online course completion for Module 1, Fundamentals of HT (21.9±2.5 to 23.7±2.5, p<0.001), and Module 2, Basics of HT Management (14.9±3.3 to 18.5±4.3, p<0.001). No statistically significant differences were evident by gender or school year. Students who took a shorter duration to complete the course had significantly higher mean score improvement between pre- and post-test (mean score improvement 7.0 if <4 weeks, 3.6 if 4-8 weeks, and 3.7 if >8 weeks, p<0.003). Students recognized information on blood pressure measurement (32.2%) and HT management (22.3%) as the most important concept addressed in the course. A self-paced online course, complementing medical school training, improved knowledge on HT burden and management in Uganda.

Transnational Capacity Building Efforts in Global Neurosurgery: A Review and Analysis of Their Impact and Determinants of Success.

BACKGROUND: Neurosurgical capacity building efforts attempt to address the shortage of neurosurgeons and lack of neurosurgical capacity in low- and middle-income countries. This review sought to characterize neurosurgical capacity building efforts in low- and middle-income countries and the challenges they face, and identify factors that predict higher engagement, better training, and performance of high-impact activities. METHODS: A scoping review using PubMed and Embase databases was performed and relevant articles were identified. Programs were classified into 6 categories and the activities they performed were classified as having a high-, medium-, or mild impact on capacity. Programs were also classified using the Olivieri engagement and training criteria. RESULTS: Fifty-seven articles representing 42 unique efforts were included. The most important determinant of impact was a program's design and intent. Furthermore, 91% of training and twinning programs received high (class 2 or 3) engagement classifications compared to 17% of mission trips and training camps (P < 0.001); 91% of training and twinning programs received high training classifications compared to 64% of mission trips and training camps (P = 0.015); and 91% of training and twinning programs reported performing high-impact activities compared to 29% of mission trips and training camps (P < 0.001). CONCLUSIONS: Training and twinning programs are more engaged, offer better training, and are more likely to perform high-impact activities compared to mission trips and training camps, suggesting that these types of programs offer the greatest chance of producing substantial and sustainable improvements to neurosurgical capacity.

Evidence for an expanded hypertension care cascade in low- and middle-income countries: a scoping review.

BACKGROUND: With nearly 90% of annual hypertension-related deaths occurring in low- and middle-income countries (LMICs), there is an urgent need to measure the coverage of health services that effectively manage hypertension. However, there is little agreement on how to define effective coverage and the existing hypertension care cascade (hypertension prevalence, percent aware, percent treated, and percent controlled) does not account for the quality of care received by patients. This study reviews definitions of effective coverage and service quality for hypertension management services and proposes an expanded hypertension care cascade to improve measurement of health systems performance. METHODS: A systematic scoping review of literature published in six electronic databases between January 2000 and October 2020 identified studies that defined effective coverage of hypertension management services or integrated dimensions of service quality into population-based estimates of hypertension management in LMICs. Findings informed an expanded hypertension care cascade from which quality-adjusted service coverage can be calculated to approximate effective coverage. RESULTS: The review identified 18 relevant studies, including 6 that defined effective coverage for hypertension management services and 12 that reported a measure of service quality in a population-based study. Based on commonly reported barriers to hypertension management, new steps on the proposed expanded care cascade include (i) population screened, (ii) population linked to quality care, and (iii) population adhering to prescribed treatment. CONCLUSION: There is little consensus on the definition of effective coverage of hypertension management services, and most studies do not describe the quality of hypertension management services provided to populations. Incorporating aspects of service quality to the hypertension care cascade allows for the calculation of quality-adjusted coverage of relevant services, enabling an appropriate measurement of health systems performance through effective coverage.

Effectiveness of instructional videos for enhancing healthcare provider competencies for hypertension management - a pre-post study in primary healthcare settings, Tanzania.

BACKGROUND: Inadequate adherence to hypertension (HT) clinical standards by healthcare providers is one of the major barriers for HT management. We examined the effectiveness of four short instructional training videos on HT management. METHODS: Eighteen primary health care facilities were randomly selected using systematic sampling from five districts in the Dar es Salaam region, Tanzania. Pre-post provider knowledge assessments were conducted six months after training and provider performance was measured using patient observations on 8-10 consecutive adult patients per facility. A Screening Quality Index (SQI), comprised of ten HT screening standards, was used to measure adherence. RESULTS: Pre-post knowledge scores improved significantly, for, time between blood pressure (BP) readings (28.1% to 72.7%, p=0.01), BP threshold for patients with complications (21.2% to 97.0%, p<0.001), and lifestyle/dietary counseling (from 36.4% to 97.0%, p<0.001). SQI was significantly higher following the training for all provider groups; Nurses (3.0±3.5 to 8.4±1.0, p<0.001), Assistant Medical Officers and Medical Officers (3.5±4.1 to 7.6±2.4, p<0.001), and Assistant Clinical Officers and Clinical Officers (5.4±3.8 to 8.4±2.0, p<0.001). After training, significantly higher adherence was evident for key aspects of managing patients with HT: e.g., counseling on medication (62.1% to 92.7%, p=0.002), side effects (41.4% to 56.1%, p=0.009), reducing caloric intake (69.0 % to 95.1%, p=0.003), reducing cooking salt (65.5% to 97.6%, p<0.01), increasing physical activity (55.2% to 92.7% p<0.001), stopping/reducing cigarette smoking (24.1% to 63.4%, p=0.001), and reducing alcohol consumption (24.1% to 68.3%, p<0.001). SQI was significantly associated with number of years of provider experience (more than 2 years), type of primary healthcare facility (public facility), and exposure to the training intervention. CONCLUSION: Training with short instructional videos can improve provider competency and clinical performance for HT management. The strategy has the potential to enhance effective implementation of HT control strategies in primary care clinics in Tanzania and elsewhere.

A comparative study of adult and adolescent maternal care continuum following community-oriented interventions in Cambodia, Guatemala, Kenya, and Zambia.

BACKGROUND: The coverage for reproductive care continuum is a growing concern for communities in low- income economies. Adolescents (15-19 years) are often at higher odds of maternal morbidity and mortality due to other underlying factors including biological immaturity, social, and economic differences. The aim of the study was to examine a) differences in care-seeking and continuum of care (4 antenatal care (ANC4+), skilled birth attendance (SBA) and postnatal care (PNC) within 24h) between adult (20-49 Years) and adolescents and b) the effect of multilevel community-oriented interventions on adolescent and adult reproductive care-seeking in Cambodia, Guatemala, Kenya, and Zambia using a quasi-experimental study design. METHODS: In each country, communities in two districts/sub-districts received timed community health worker (CHW) household health promotion and social accountability interventions with community scorecards. Two matched districts/sub-districts were selected for comparison and received routine healthcare services. RESULTS: Results from the final evaluation showed that there were no significant differences in the care continuum for adolescents and adults except for Kenya (26.1% vs 18.8%, p<0.05). SBA was significantly higher for adolescents compared to adult women for Guatemala (64% vs 55.5%, p<0.05). Adolescents in the intervention sites showed significantly higher ANC utilization for Kenya (95.3% vs 84.8%, p<0.01) and Zambia (87% vs 72.7%, p<0.05), ANC4 for Cambodia (83.7% vs 43.2%, p<0.001) and Kenya (65.9% vs 48.1%, p<0.05), SBA for Cambodia (100% vs 88.9%, p<0.05), early PNC for Cambodia (91.8% vs 72.8%, p<0.01) and Zambia (56.5% vs 16.9%, p<0.001) compared to the comparison sites. However, the findings from Guatemala illustrated significantly lower care continuum for intervention sites (aOR:0.34, 95% CI 0.28-0.42, p<0.001). The study provides some evidence on the potential of multilevel community-oriented interventions to improve adolescent healthcare seeking in rural contexts. The predictors of care continuum varied across countries, indicating the importance of contextual factors in designing interventions.

Barriers to effective hypertension management in rural Bihar, India: A cross-sectional, linked supply- and demand-side study.

Effective management of hypertension in low- and middle-income settings is a persistent public health challenge. This study examined supply- and demand-side barriers to receiving quality care and achieving effective hypertension management in rural Bihar, India. A state-representative household survey collected information from adults over 30 years of age on characteristics of the hypertension screening, diagnosis, and management services they received. A linked provider assessment determined the percent of providers who provided quality hypertension care (i.e., had a functioning BP measurement device, measured a patient's BP, could correctly diagnose hypertension, had at least one first-line antihypertension medication, and could prescribe correctly based on standard guidelines). Patients were linked with their provider to determine the quality-adjusted coverage of hypertension management and logistic regression analysis was conducted to determine characteristics associated with receiving quality care. A total of 14,386 patients and 390 providers were studied. Nearly a quarter (22.5%) of adults had never had their BP measured before and 8.1% of adults reported a previous hypertension diagnosis. Less than one third (31.0%) of all interviewed providers demonstrated ability to provide quality hypertension care, and quality varied between provider types (14.8% of private homeopathic, 25.2% of informal, 40.0% of private modern medicine, and 60.0% of public providers gave quality care). While 95.8% of diagnosed individuals received some treatment, only 10.9% of patients received care from quality local providers. Nearly 45% of individuals with hypertension received care from non-local providers. Individuals from the general caste with comorbidities living in villages with more high-quality providers were most likely to receive quality care from a local provider. Whereas the coverage of services for individuals diagnosed with hypertension is high, the quality of these services is suboptimal for economically and socially vulnerable populations, which limits effective management and control of hypertension in rural Bihar. Efforts should be targeted towards providers to initiate quality treatment upon diagnosis, including correct prescription of antihypertensives.

Patient and healthcare provider perspectives on adherence with antihypertensive medications: an exploratory qualitative study in Tanzania.

BACKGROUND: Poor medication adherence is an extraordinarily common problem worldwide that contributes to inadequate control of many chronic diseases, including Hypertension (HT). Globally, less than 14% of the estimated 1.4 billion patients with HT achieve optimal control. A myriad of barriers, across patient, healthcare provider, and system levels, contributes to poor medication adherence. Few studies have explored the reasons for poor medication adherence in Tanzania and other African countries. METHODS: A qualitative study applying grounded theory principles was conducted in the catchment area of two semi-urban clinics in Dar es Salaam, Tanzania, to determine the perceived barriers to HT medication adherence. Ten key informant interviews were conducted with healthcare providers who manage HT patients. Patients diagnosed with HT (SBP ≥ 140 and DBP ≥ 90), were randomly selected from patient registers, and nine focus group discussions were conducted with a total 34 patients. Inductive codes were developed separately for the two groups, prior to analyzing key thematic ideas with smaller sub-categories. RESULTS: Affordability of antihypertensive medication and access to care emerged as the most important barriers. Fee subsidies for treatment and medication, along with health insurance, were mentioned as potential solutions to enhance access and adherence. Patient education and quality of physician counseling were mentioned by both providers and patients as major barriers to medication adherence, as most patients were unaware of their HT and often took medications only when symptomatic. Use of local herbal medicines was mentioned as an alternative to medications, as they were inexpensive, available, and culturally acceptable. Patient recommendations for improving adherence included community-based distribution of refills, SMS text reminders, and family support. Reliance on religious leaders over healthcare providers emerged as a potential means to promote adherence in some discussions. CONCLUSIONS: Effective management of hypertensive patients for medication adherence will require several context-specific measures. These include policy measures addressing financial access, with medication subsidies for the poor and accessible distribution systems for medication refill; physician measures to improve health provider counseling for patient centric care; and patient-level strategies with reminders for medication adherence in low resource settings.

Can people-centered community-oriented interventions improve skilled birth attendance? Evidence from a quasi-experimental study in rural communities of Cambodia, Kenya, and Zambia.

BACKGROUND: Skilled attendance at delivery is a key marker for reducing maternal mortality. Effective community engagement strategies complemented by community health worker (CHW) services can improve access to maternal health services in areas with limited health infrastructure or workforce. METHODS: A quasi-experimental study with matched comparison groups was conducted in Cambodia, Kenya and Zambia to determine the effect of integrated community investments on skilled birth attendance (SBA). In each country, communities in two districts/sub-districts received a package of community-oriented interventions comprised of timed CHW household health promotion for maternal, newborn and child health complemented by social accountability mechanisms using community scorecards. Two matched comparison districts/sub-districts received ongoing routine interventions. Data from the final evaluation were examined to determine the effect of timed CHW services and community-oriented interventions on SBA. RESULTS: Over 80% of the 3037 women in Cambodia, 2805 women in Kenya and 1171 women in Zambia reported SBA. Women in intervention sites who received timely CHW health promotion and social accountability mechanisms in Cambodia showed significantly higher odds of SBA (aOR = 7.48; 95% CI: 3.87, 14.5). The findings also indicated that women over the age of 24 in Cambodia, women with primary or secondary education in Cambodia and secondary education in Kenya, women from higher wealth quintiles in Cambodia, and women with four or more antenatal care (ANC) visits in all countries reported significantly higher odds of SBA. Inclusion of family members in pregnancy-related discussions in Kenya (aOR = 2.12; 95% CI: 1.06, 4.26) and Zambia (aOR = 6.78; 95% CI: 1.15, 13.9) and follow up CHW visits after a referral or health facility visit (aOR = 2.44; 95% CI: 1.30, 4.60 in Cambodia; aOR = 2.17; 95% CI 1.25, 3.75 in Kenya; aOR = 1.89; 95% CI: 1.05, 2.02 in Zambia) also showed significantly greater odds of SBA. CONCLUSIONS: Enhancing people-centered care through culturally appropriate community-oriented strategies integrating timely CHW health promotion and social accountability mechanisms shows some evidence for improving SBA during delivery. These strategies can accelerate the achievement of the sustainable development goals for maternal child and newborn health.

Can social accountability mechanisms using community scorecards improve quality of pediatric care in rural Cambodia?

OBJECTIVE: To determine the effect of social accountability strategies on pediatric quality of care. DESIGN AND SETTING: A non-randomized quasi experimental study was conducted in four districts in Cambodia and all operational public health facilities were included. PARTICIPANTS: Five patients under 5 years and their caretakers were randomly selected in each facility. INTERVENTIONS: To determine the effect of maternal and child health interventions integrating citizen voice and action using community scorecards on quality of pediatric care. OUTCOME MEASURES: Patient observations were conducted to determine quality of screening and counseling, followed by exit interviews with caretakers. RESULTS: Results indicated significant differences between intervention and comparison facilities; screening by Integrated Management of Childhood Illness (IMCI) trained providers (100% vs 67%, P < 0.019), screening for danger signs; ability to drink/breastfeed (100% vs 86.7%, P < 0.041), lethargy (86.7% vs 40%, P < 0.004) and convulsions (83.3 vs 46.7%, P < 0.023). Screening was significantly higher for patients in the intervention facilities for edema (56.7% vs 6.7%, P < 0.000), immunization card (90% vs 40%, P < 0.002), child weight (100 vs 86.7, P < 0.041) and checking growth chart (96.7% vs 66.7%, P < 0.035). The IMCI index, constructed from key performance indicators, was significantly higher for patients in the intervention facilities than comparison facilities (screening index 8.8 vs 7.0, P < 0.018, counseling index 2.7 vs 1.5, P < 0.001). Predictors of screening quality were child age, screening by IMCI trained provider, wealthier quintiles and intervention facilities. CONCLUSION: The institution of social accountability mechanisms to engage communities and facility providers showed some improvements in quality of care for common pediatric conditions, but socioeconomic disparities were evident.

An exploratory study on the quality of patient screening and counseling for hypertension management in Tanzania.

BACKGROUND: The global burden of hypertension, currently estimated at 1 billion, is a leading Non-Communicable Disease (NCD) in Sub Saharan Africa. In Tanzania, the reported prevalence of hypertension is 25%. Inherent limitations of the healthcare system to control hypertension include inadequate provider knowledge, system capacity, medication access, and patient awareness, all of which hinder effective screening and disease management. To assess the quality of hypertension screening and patient counseling, we conducted a study in an ambulatory setting in Tanzania. METHODS: Observations of patient screening were conducted on 69 adult patients during routine outpatient care and screening camps. In addition, 33 healthcare providers participated in a pre-post knowledge assessment after observing instructional training videos. RESULTS: Patient observations indicated that blood pressure (BP) measurement was explained to 65% of patients, and 77% of the measurements were made with mercury sphygmomanometers. For several aspects of BP measurement, nurses performed better than doctors: patient's arm supported on a flat surface (doctors, 58% vs nurses 67%, p<0.05), and patient's back was supported (doctors, 50% vs nurses 88%, p<0.01). Among those diagnosed with hypertension, 7% were prescribed medications, 14% were advised on reduced salt during cooking, 29% on reduced salt consumption, 21% on reduced consumption of sodium rich foods, 21% on reducing caloric intake, 21% on increasing physical activity, and 43% were informed about follow up appointments. Provider knowledge assessments showed critical gaps in consequences of hypertension, 1st line medicines, and awareness of guidelines at baseline. Following the instructional videos there were improvements in some aspects: diagnostic criteria for hypertension (pre 45% vs post 91%, p<0.001) and counseling for controlling hypertension (pre 30% vs post 58%, p<0.01). CONCLUSION: Enhancing knowledge and performance competencies of health providers at the primary care level is a critical prerequisite for effective hypertension management in low resource settings.

Institutionalizing quality within national health systems: key ingredients for success.

Quality improvement initiatives can be fragmented and short-term, leading to missed opportunities to improve quality in a systemic and sustainable manner. An overarching national policy or strategy on quality, informed by frontline implementation, can provide direction for quality initiatives across all levels of the health system. This can strengthen service delivery along with strong leadership, resources, and infrastructure as essential building blocks for the health system. This article draws on the proceedings of an ISQua conference exploring factors for institutionalizing quality of care within national systems. Active learning, inclusive of peer-to-peer learning and exchange, mentoring and coaching, emerged as a critical success factor to creating a culture of quality. When coupled by reinforcing elements like strong partnerships and coordination across multiple levels, engagement at all health system levels and strong political commitment, this culture can be cascaded to all levels requiring policy, leadership, and the capabilities for delivering quality healthcare.

Are children presenting with non-IMCI complaints at greater risk for suboptimal screening? An analysis of outpatient visits in Afghanistan.

OBJECTIVE: To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions. DESIGN: Cross-sectional study. SETTING: Thirty-three provinces in Afghanistan. PARTICIPANTS: Observation of 3072 sick child visits selected by systematic random sampling. MAIN OUTCOME MEASURE(S): A 10 point IMCI assessment index. RESULTS: One hundred and thirty-one (4.3%) of the 3072 sick child visits involved no IMCI-related complaints. The mean assessment index for all sick child visits was 4.81 (SD 2.41). Visits involving any IMCI-related complaint were associated with a 1.02 point higher mean assessment index than those without IMCI-related complaints (95% CI, 0.52-1.53; P < 0.001). After adjusting for relevant covariates including patient age, caretaker gender, provider type, provider gender, provider IMCI training status and IMCI guideline availability, we found that children with IMCI-related presenting complaints had a significantly better quality of IMCI screening, than those without IMCI presenting complaints (by 0.75 points; 95% CI, 0.25-1.26; P = 0.003). CONCLUSIONS: Our study indicates that children with non-IMCI presenting complaints are at greater risk of suboptimal screening compared to children with IMCI-related presenting complaints. The premise of IMCI is to routinely screen all children for conditions responsible for the major burden of childhood disease in countries like Afghanistan. The study illustrates an important finding that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination to ensure that all children receive routine screening for common IMCI conditions.

Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda.

BACKGROUND: Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up. METHODS: We draw upon three IR studies conducted by Future Health Systems (FHS) in Afghanistan, Bangladesh and Uganda. We reviewed project documents from the period 2011-2016 to identify information related to the dimensions of scaling up. Further, for each country, we developed rich descriptions of how the research teams approached scaling up, and how IR contributed to scale-up. The rich descriptions were checked by FHS research teams. We identified common patterns and differences across the three cases. RESULTS: The three cases planned quite different innovations/interventions and had very different types of scale-up strategies. In all three cases, the research teams had extensive prior experience within the study communities, and little explicit attention was paid to contextual factors. All three cases involved complex interactions between the research teams and other stakeholders, among stakeholders, and between stakeholders and the intervention. The IR planned by the research teams focussed primarily on feasibility and effectiveness, but in practice, the research teams also had critical insights into other factors such as sustainability, acceptability, cost-effectiveness and appropriateness. Stakeholder analyses and other project management tools further complemented IR. CONCLUSIONS: IR can provide significant insights into how best to scale-up a particular intervention. To take advantage of insights from IR, scale-up strategies require flexibility and IR must also be sufficiently flexible to respond to new emerging questions. While commonly used conceptual frameworks for scale-up clearly delineate actors, such as implementers, target communities and the support team, in our experience, IR blurred the links between these groups.

Measuring pediatric quality of care in rural clinics-a multi-country assessment-Cambodia, Guatemala, Zambia and Kenya.

OBJECTIVE: To assess the quality of care provided in rural pediatric facilities in Cambodia, Guatemala, Kenya and Zambia DESIGN: All public health facilities in four districts in each country were included in the assessment. Based on utilization patterns, five children under five were selected randomly from each facility to perform the Integrated Management of Childhood Illness (IMCI) assessments followed by exit interviews with their caretakers. SETTING: Seventy rural ambulatory pediatric care facilities. PARTICIPANTS: Three hundred and forty pediatric case management observations and exit interviews with child caretakers. MAIN OUTCOME MEASURE: IMCI index of observed quality of care for patient assessment and counseling RESULTS: Screening for danger signs, diarrhea and fever showed significant differences between countries (P < 0.001), with facilities in Cambodia and Guatemala performing better. More than 90% of the children were screened for fever in all three countries, but <75% were screened in Cambodia. The assessment of nutritional status, checking weight against growth chart and palmar pallor for anemia, was suboptimal in all countries. Mean consultation time ranged from 8.2 minutes in Zambia and 12.6 minutes in Guatemala. Child age, consultation time, health provider cadre and presenting symptoms were significantly associated with higher quality of assessment and counseling care as measured by the IMCI index. CONCLUSIONS: Achieving the goals of universal health coverage in these contexts must be complimented with accelerated efforts for capacity investments at the primary care level to ensure optimal quality of healthcare and favorable health outcomes for children, who still experience a high disease burden for these common IMCI conditions.

Effectiveness of a pay-for-performance intervention to improve maternal and child health services in Afghanistan: a cluster-randomized trial.

BACKGROUND: A cluster randomized trial of a pay-for-performance (P4P) scheme was implemented in Afghanistan to test whether P4P could improve maternal and child (MCH) services. METHODS: All 442 primary care facilities in 11 provinces were matched by type of facility and outpatient volume, and randomly assigned to the P4P or comparison arm. P4P facilities were given bonus payments based on the MCH services provided. An endline household sample survey was conducted in 72 randomly selected matched pair catchment areas (3421 P4P households; 3427 comparison).The quality of services was assessed in 81 randomly sampled matched pairs of facilities. Data collectors and households were blinded to the intervention assignment. MCH outcomes were assessed at the cluster level. RESULTS: There were no substantial differences in any of the five MCH coverage indicators (P4P vs comparison): modern contraception(10.7% vs 11.2% (P = 0.90); antenatal care: 56.2% vs 55.6% (P = 0.94); skilled birth attendance (33.9% vs 28.5%, P = 0.17); postnatal care (31.2% vs 30.3%, P = 0.98); and childhood pentavalent3 vaccination (49.6 vs 52.3%, P = 0.41), or in the equity measures. There were substantial increases in the quality of history and physical examinations index (P = 0.01); client counselling index (P = 0.01); and time spent with patients (P = 0.05). Health workers reported limited understanding about the bonuses. CONCLUSIONS: The intervention had minimal effect, possibly due to difficulties communicating with health workers and inattention to demand-side factors. P4P interventions need to consider management and community demand issues.

Enhancing governance and health system accountability for people centered healthcare: an exploratory study of community scorecards in Afghanistan.

BACKGROUND: The premise of patient-centered care is to empower patients to become active participants in their own care and receive health services focused on their individual needs and preferences. Afghanistan has evidenced enormous gains in coverage and utilization, but the quality of care remains suboptimal, as evidenced in the balanced scorecard (BSC) performance assessments. In the United States and throughout Africa and Asia, community scorecards (CSC) have proved effective in improving accountability and responsiveness of services. This study represents the first attempt to assess CSC feasibility in a fragile context (Afghanistan) through joint engagement of service providers and community members in the design of patient-centered services with the objective of assessing impact on service delivery and perceived quality of care. METHODS: Six primary healthcare facilities were randomly selected in three provinces (Bamyan, Takhar and Nangarhar) and communities in their catchment area were selected for the study. Employing a multi-stakeholder strategy, community members and leaders, health councils, facility providers, NGO managers, and provincial directorates were engaged in a five-phase process to jointly identify structural and service delivery indicators (about 20), score performance and subsequently develop action plans for instituting improvements through participatory research methods. Three rounds of CSC assessments were conducted in each community. Over 470 community members, 34 health providers, and other provincial ministry staff participated in the performance audits. RESULTS: Structural capacity indicators including the number and cadre of service providers, particularly female providers, water and power supply, waiting rooms, essential medicines, and equipment scored low in the first round (30-50%). Provider courtesy and quality of care received high scores (>90%) throughout the study. Unrealistic community demands for ambulances and specialist doctors were mitigated by community education of entitlements described in the national standards for essential package of services. The joint interface meeting facilitated transparent dialogue between the community and providers and resulted in creative and participatory problem solving mechanisms and mobilization of resources. CONCLUSION: These results indicate the potential of the CSC as a tool for enhancing social accountability for patient-centered care. However, the process requires skilled facilitators to effectively engage communities and healthcare providers and adaptation to specific healthcare contexts.

Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system.

Global efforts to scale-up the community health workforce have accelerated as a result of the growing evidence of their effectiveness to enhance coverage and health outcomes. Reconstruction efforts in Afghanistan integrated capacity investments for community based service delivery, including the deployment of over 28,000 community health workers (CHWs) to ensure access to basic preventive and curative services. The study aimed to conduct capacity assessments of the CHW system and determine stakeholder perspectives of CHW performance. Structured interviews were conducted on a national sample from 33 provinces and included supervisors, facility providers, patients, and CHWs. Formative assessments were also conducted with national policymakers, community members and health councils in two provinces. Results indicate that more than 70% of the NGO's provide comprehensive training for CHWs, 95% CHWs reported regular supervision, and more than 60% of the health posts had adequate infrastructure and essential commodities. Innovative strategies of paired male and female CHWs, institution of a special cadre of community health supervisors, and community health councils were introduced as systems strengthening mechanisms. Reported barriers included unrealistic and expanding task expectations (14%), unsatisfactory compensation mechanisms (75%), inadequate transport (69%), and lack of commodities (40%). Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-h care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care. The study provides critical insight into the strengths and constraints of Afghanistan's CHW system, warranting further efforts to contextualize service delivery and mechanisms for their support and motivation.

Peace-building and reconciliation dividends of integrated health services delivery in post-conflict Burundi: qualitative assessments of providers and community members.

While demonstrating causality remains challenging, several 'health-peace' mechanisms have been proposed to describe how health systems contribute to peace-building and stability in post-conflict settings. A qualitative study was undertaken in southern Burundi to identify drivers of social tension and reconciliation in the catchment area of Village Health Works, a health services organisation. Key informant interviews and focus group discussions were conducted in early 2014 with a total of one hundred and twenty community members and staff representing a range of conflict and recovery experience. Themes emerging from these interviews indicated mechanisms at the individual, household, community, and regional levels through which health provision mitigates tensions and promotes social cohesion. This peace dividend was amplified by the clinic's integrated model, which facilitates further community interaction through economic, agricultural and education programmes. Land pressure and the marginalisation of repatriated refugees were cited as drivers of local tension.

The association of health workforce capacity and quality of pediatric care in Afghanistan.

OBJECTIVE: To examine the relationship between workforce capacity and quality of pediatric care in outpatient clinics in Afghanistan. DESIGN: Annual national performance assessments were conducted between 2005 and 2008 to determine quality of care through patient observations in >600 health facilities, selected by stratified random sampling each year. Other variables measured were health provider capacity, competency and adequacy of support systems. SETTING: Primary care facilities in 29 provinces in Afghanistan. PARTICIPANTS: Pediatric patients and their caretakers greater than 2400 were selected at random each year. MAIN OUTCOME MEASURES: Index of observed quality of care for patient assessment and counseling based on WHO's Integrated Management of Childhood Illness (IMCI) clinical guidelines. RESULTS: Quality of care improved for all IMCI indices between 2005 and 2008 (IMCI index increased from 43.1 to 56.1; P < 0.001) and was significantly associated with the availability of doctors, IMCI training and knowledge and factors such as provider job satisfaction, availability of clinical guidelines, frequency of supervision and the presence of community councils. There was also a progressive increase in the index summarizing staffing capacity during the study period. Basic health centers increased from 75.6 to 85.5% (P < 0.001), comprehensive health centers increased from 27.9 to 37.9% (P < 0.03) and district hospitals increased from 34.1 to 37.2% (P > 0.05). CONCLUSIONS: Enhancing workforce capacity and competency and ensuring appropriate supervision and systems support mechanisms can contribute to improved quality of care. Although the results indicate sustained improvements over the study period, further research on the mixture of provider skills, competency and factors influencing provider motivation are essential to determine the optimal workforce capacity in Afghanistan.