RESUMO
CONTEXT AND OBJECTIVES: Non-communicable diseases and injuries (NCDIs) comprise a large share of mortality and morbidity in low-income countries (LICs), many of which occur earlier in life and with greater severity than in higher income settings. Our objective was to assess availability of essential equipment and medications required for a broad range of acute and chronic NCDI conditions. DESIGN: Secondary analysis of existing cross-sectional survey data. SETTING: We used data from Service Provision Assessment surveys in Bangladesh, the Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal and Tanzania, focusing on public first-referral level hospitals in each country. OUTCOME MEASURES: We defined sets of equipment and medications required for diagnosis and management of four acute and nine chronic NCDI conditions and determined availability of these items at the health facilities. RESULTS: Overall, 797 hospitals were included. Medication and equipment availability was highest for acute epilepsy (country estimates ranging from 40% to 95%) and stage 1-2 hypertension (28%-83%). Availability was low for type 1 diabetes (1%-70%), type 2 diabetes (3%-57%), asthma (0%-7%) and acute presentations of diabetes (0%-26%) and asthma (0%-4%). Few hospitals had equipment or medications for heart failure (0%-32%), rheumatic heart disease (0%-23%), hypertensive emergencies (0%-64%) or acute minor surgical conditions (0%-5%). Data for chronic pain were limited to only two countries. Availability of essential medications and equipment was lower than previous facility-reported service availability. CONCLUSIONS: Our findings demonstrate low availability of essential equipment and medications for diverse NCDIs at first-referral level hospitals in eight LICs. There is a need for decentralisation and integration of NCDI services in existing care platforms and improved assessment and monitoring to fully achieve universal health coverage.
Assuntos
Diabetes Mellitus Tipo 2 , Doenças não Transmissíveis , Adulto , Bangladesh , Estudos Transversais , Etiópia , Haiti , Hospitais Públicos , Humanos , Malaui , Nepal , Doenças não Transmissíveis/tratamento farmacológico , Doenças não Transmissíveis/epidemiologia , Encaminhamento e Consulta , Senegal , TanzâniaRESUMO
Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and middle-income countries. In such countries, many deliveries occur at primary care facilities, where the quality of care is poor. We modeled the geographic feasibility of service delivery redesign that shifted deliveries from primary care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania. We estimated the proportion of women within two hours of the nearest delivery facility, both currently and under redesign. Today, 83-100 percent of pregnant women in the study countries have two-hour access to a delivery facility. A policy of redesign would reduce two-hour access by at most 10 percent, ranging from 0.6 percent in Malawi to 9.9 percent in Tanzania. Relocating delivery services to hospitals would not unduly impede geographic access to care in the study countries. This policy should be considered in low- and middle-income countries, as it may be an effective approach to reducing maternal and newborn deaths.
Assuntos
Instalações de Saúde , Obstetrícia , Melhoria de Qualidade/organização & administração , Qualidade da Assistência à Saúde , Feminino , Haiti , Política de Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Quênia , Malaui , Namíbia , Nepal , Gravidez , TanzâniaRESUMO
BACKGROUND: Expanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti. METHODS: We constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery. RESULTS: Facilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure. CONCLUSIONS: Poor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.
Assuntos
Atenção Primária à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Transversais , Haiti , Humanos , População Rural/estatística & dados numéricosRESUMO
OBJECTIVE: Describe content of clinical care for sick children in low-resource settings. DATA SOURCES: Nationally representative health facility surveys in Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda from 2007 to 2015. STUDY DESIGN: Clinical visits by sick children under 5 years were observed and caregivers interviewed. We describe duration and content of the care in the visit and estimate associations between increased content and caregiver knowledge and satisfaction. PRINCIPAL FINDINGS: The median duration of 15,444 observations was 8 minutes; providers performed 8.4 of a maximum 24 clinical actions per visit. Content of care was minimally greater for severely ill children. Each additional clinical action was associated with 2 percent higher caregiver knowledge. CONCLUSIONS: Consultations for children in nine lower-income countries are brief and limited. A greater number of clinical actions was associated with caregiver knowledge and satisfaction.
Assuntos
Cuidadores/psicologia , Serviços de Saúde da Criança , Conhecimentos, Atitudes e Prática em Saúde , Qualidade da Assistência à Saúde/normas , Encaminhamento e Consulta/estatística & dados numéricos , África , Serviços de Saúde da Criança/normas , Mortalidade da Criança/tendências , Pré-Escolar , Feminino , Haiti , Instalações de Saúde , Humanos , Lactente , Recém-Nascido , Entrevistas como Assunto , Masculino , Nepal , PobrezaRESUMO
OBJECTIVE: To develop a composite measure of primary care quality and apply it to Haiti's primary care system. METHODS: Using the Primary Health Care Performance Initiative's framework, we defined four domains of primary care service delivery: (i) accessible care; (ii) effective service delivery; (iii) management and organization; and (iv) primary care functions. We gave each primary care facility in Haiti a quality score for each domain and overall, with poor, fair and good quality indicated by scores of 0.00-0.49, 0.50-0.74 and 0.75-1.00, respectively. We quantified access and effective access to primary care as the proportions of the population within 5 km of any primary care facility and a good facility, respectively. FINDINGS: Of the 786 primary care facilities in Haiti in 2013, only 332 (43%) facilities were classified as good for accessible care. Fewer facilities were classified as good in the domains of effective service delivery (30; 4%), management and organization (91; 12%) and primary care functions (43; 5%). Although about 91% of the population lived within 5 km of a primary care facility, only an estimated 23% of the entire population - including just 5% of the rural population - had access to primary care of good quality. CONCLUSION: Despite an extensive network of health facilities, a minority of Haitians had access to a primary care facility of good quality. Such facilities were especially scarce in rural areas. Similar systematic analyses of the quality of primary care could inform national efforts to strengthen health systems.