Menu ENN Search

Proposal of a Quality of Care Index

View this article as a pdf

Summary of research1

Location: Global

What we know: Efforts are needed to ensure provision of effective, high-quality care across health services.

What this article adds: While health management information systems continue to develop, periodic health facility surveys like the Service Provision Assessment (SPA) provide information to monitor progress and target interventions. However, these surveys are complex and consensus around key quality of care indicators or summary measures is lacking. This report proposes a short list of indicators that measure readiness for and provision of highly effective interventions and propose a quality of care index (QOCI) that spans reproductive, maternal, newborn and child health and nutrition (RMNCHN) as well as Water, sanitation and hygiene (WASH). An analysis using the QOCI is included for the seven countries that have completed a national SPA survey since 2013: Bangladesh, Democratic Republic of Congo, Haiti, Malawi, Nepal, Senegal and Tanzania. QOCI scores revealed differences within countries as well as differences in and among the services themselves. This study serves as a starting point for further discussion on how to create a concise and practical summary measure of quality of care so that decision makers and stakeholders can identify weakness within the health system and address gaps through targeted improvement efforts.

As the use of health facilities along the continuum of care for women and children increases globally, efforts are needed to focus on the provision of effective, high-quality care across services to end preventable maternal and child morbidity and death. It is no longer enough to measure the coverage of reproductive, maternal, newborn and child health and nutrition (RMNCHN) interventions without considering whether the services provided by facilities are adequate. Advancements in the measurement of the quality of care are however needed.

The Service Provision Assessment (SPA) is a health facility survey that provides a comprehensive overview of a country’s health service delivery. It is one type of survey proposed by The Demographic and Health Surveys Program, one of the principal sources of international data on the provision of health services. Although critiqued for being complex or for their data being difficult to use, periodically conducted SPA surveys, or similar national health facility surveys that include observation of services, are critical sources of information on quality of care. Provision of care and selected services can be captured through health management information systems at lower administrative levels, even at the facility level, and at more frequent intervals. However, these systems are still under development and are often limited by lack of representativeness, incomplete reporting and not typically being publicly available.

This paper presents an initial attempt to select a short list of indicators that measure readiness for and provision of highly effective interventions and proposes to create a quality of care index (QOCI) – one singular measure of services built from data that are available in SPA. A set of RMNCHN and Water, sanitation and hygiene (WASH) indicators were determined based on scientific evidence, international guidelines and with input from technical experts. RMNCH indicators covered five services – family planning, antenatal care (ANC), delivery care, immunisation and child curative care. The final list of 17 indicators selected reflects structural readiness at the facility level (e.g., does the facility have first-line antibiotics?) as well as process components of quality service delivery which are measured at the client level (e.g., were children assessed for dehydration?).

An analysis using the QOCI is included for the seven countries that have completed a national SPA survey since 2013: Bangladesh, Democratic Republic of Congo, Haiti, Malawi, Nepal, Senegal and Tanzania. Quality could not be directly compared across countries given the differences in indicators and the timing of surveys and thus the findings are reported separately for each country.

Within many countries, the quality of care varied from region to region. Regional variation was most prominent in the DRC, with 48 points between the highest- and lowest-scoring regions. The three countries with the lowest variation among regions were those with the fewest regions, Bangladesh, Malawi and Nepal.

QOCI scores also revealed differences in and among the services themselves. In five of the seven countries included, WASH was the highest-scoring service (Bangladesh, Haiti, Malawi, Nepal and Senegal), ranging from 66% to 81% of facilities with basic WASH services. Conversely, the immunisation service was the lowest scoring area in three countries (Bangladesh, Malawi and Nepal) and the second lowest-scoring domain in the DRC. Although immunisation was the second highest-scoring service in Tanzania, the availability of immunisations at facilities ranged by 88 percentage points between its highest- and lowest-scoring regions. Within ANC, the blood pressure indicator scored high across most countries. In five out of the six countries in which it was measured, more than 70% of clients had their blood pressure measured. Across all countries, the percentage of facilities with oral rehydration salts (ORS) or zinc in stock for diarrhoea was also high. In five of this study’s seven countries, more than 80% of facilities provided ORS or zinc for diarrhoea. In contrast, few clients had a full nutritional status assessment. Of the facilities in the DRC, Haiti, Malawi, Nepal and Tanzania, 2% or fewer included a nutritional status assessment during child curative care.

Scores for individual indicators ranged even more dramatically. In Senegal, for example, the ANC service area index score is 49 but this area also had the highest and lowest scoring indicators (blood pressure measurement and breastfeeding counselling, respectively).

Where comparable items were available across countries, the analysis found that nutritional status was rarely assessed during child curative care visits. Conversely, availability of ORS or zinc for diarrhoea, WASH resources, immunisations and blood pressure measurements during antenatal care were common.

This report does not provide external validation for the index or the indicators. Rather, both the index and indicators were chosen to serve as tracers for quality of care – a starting point for launching a conversation about which areas need to be more holistically explored to improve quality of care so that decision makers and stakeholders can identify weakness within the health system and address gaps through targeted improvement efforts. Ideally, the indicators could be assessed alongside health outcome data from population surveys or health management information systems to better understand gaps within the health system.

 

Subscribe freely to receive Field Exchange content to your mailbox or front door.

Read more...

Endnotes

1 Mallick, Lindsay, Rukundo K. Benedict, Courtney Allen, and Bradley Janocha. 2020. Proposal of a Quality of Care Index (QOCI). DHS Methodological Report No. 29. Rockville, Maryland, USA: ICF.

More like this

Nepal’s success story: What helped to improve maternal anaemia?

View this article as a pdf Dr Ram Padarath Bichha is Director of the Family Welfare Division, Department of Health Services, Ministry of Health and Population, Nepal. Kedar...

Addressing maternal nutrition service delivery gaps in Afghanistan: Policy and programming opportunities

View this article as a pdf Dr Zakia Maroof is a Nutrition Specialist working with UNICEF Afghanistan. Dr Homayoun Ludin is an Afghan doctor working with the Ministry of...

FEX: Nutrition Exchange (NEX) South Asia: Maternal nutrition

View this article as a pdf In its first-ever regional issue, Nutrition Exchange has partnered with the United Nations Children's Fund (UNICEF) Regional Office of South Asia...

FEX: Creating an enabling policy environment for effective CMAM implementation in Malawi

By Mr Sylvester Kathumba Mr Sylvester Kathumba is Principal Nutritionist with the Ministry of Health, Malawi. This article was authored by Mr Sylvester Kathumba with policy...

FEX: Screening for maternal and child malnutrition using sentinel-based national nutrition surveillance in Afghanistan

By Admire Chinjekure, Dr Mohammad Qasem Shams, Dr Abdul Baseer Qureshi, Dr Shafiqullah Safi and Dr Noor Rahman Noor View this article as a pdf Lisez cet article en...

FEX: Call to Action on improving Water, Sanitation, and Hygiene for Maternal and Newborn Health

Summary of paper1 Location: Global What we know: Water, sanitation, and hygiene (WASH) may impact maternal and newborn health (MNH). What this article adds: A recent...

FEX: CMAM scale-up: experience from Ethiopia’s El Niño response 2016

By Christoph Andert, Zeine Muzeiyn, Hatty Barthorp and Sinead O'Mahony Lisez cet article en français ici Christoph Andert is a Nutrition Advisor at GOAL's HQ. For the...

FEX: Quantity through quality: Scaling up CMAM by improving programmes Access

By Saul Guerrero & Maureen Gallagher Saul Guerrero is the Senior Evaluations, Learning and Accountability (ELA) Advisor at ACF UK based in London. Prior to joining ACF, he...

FEX: Integration of family planning in nutrition programming: experiences from the Suaahara II programme in Nepal

View this article as a pdf By Basant Thapa, Manisha Laxmi Shrestha, Dr. Bhuwan Poudel, Ganga Khadka, Bijendra Banjade and Dr. Kenda Cunningham Basant Thapa is a family...

FEX: The roll out of IMAM in Kenya’s urban slums

By Koki Kyalo, Claire Orengo, Regine Kopplow Koki Kyalo is the Urban Nutrition Programme Manager at Concern Worldwide, Kenya. She has worked with Concern Worldwide for five...

FEX: Meeting demand peaks for CMAM in government health services in Kenya

By Regine Kopplow, Yacob Yishak, Gabrielle Appleford and Wendy Erasmus Regine Kopplow is a Global Nutrition Advisor with Concern Worldwide. She previously worked in various...

NEX South Asia Editorial

Nutrition Exchange (NEX) is a long-standing ENN publication that captures the different experiences of countries in preventing and treating malnutrition. The focus of NEX has...

FEX: Effects of performance payments to health workers in Rwanda

Summary of published research1 A study just published in the Lancet set out to assess the effect of performance-based payment of healthcare providers on the use and quality of...

FEX: The state of global SAM management coverage 2012

Summary of report1 Thanks to Saul Guerrero, ACF-UK, for preparing this article. Location: Global What we know: Geographical coverage and treatment coverage are needed to...

NEX: Breaking the cycle of malnutrition: Designing an adolescent programme in Nepal

Lisez cet article en français ici View this article as a pdf Min Raj Gyawali is the Senior Manager for Health Services with the Suaahara II programme in...

FEX: Experiences of the Integrated Management of Acute Malnutrition (IMAM) programme in Nepal: from pilot to scale up

View this article as a pdf Lisez cet article en français ici Click here to listen to an interview with one of the authors on the ENN podcast channel By Karan Courtney...

FEX: From the editor

This issue of Field Exchange gives extended coverage to a briefing paper just released by Oxfam and SC UK on the 2011 response to the Horn of Africa crisis. This paper argues...

FEX: Timely expansion of nutrition development activities in repose to an acute flooding emergency in Malawi

By Natasha Lelijveld, Elizabeth Molloy, Jennifer Weiss, Gwyneth Hogley Cotes Natasha Lelijveld has recently completed a nutrition research project in Blantyre, Malawi and is...

NEX: Experiences of the Integrated Management of Acute Malnutrition (IMAM) programme in Nepal: from pilot to scale-up

This is a summary of a Field Exchange field article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by Karan...

FEX: Experiences of the Integrated Management of Acute Malnutrition (IMAM) programme in Nepal: from pilot to scale-up

This is a summary of a Field Exchange field article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by Karan...

Close

Reference this page

Proposal of a Quality of Care Index. Field Exchange 64, January 2021. p101. www.ennonline.net/fex/64/qualityofcareindexdhs

(ENN_6920)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.