Publications

INTRODUCTION: The COVID-19 pandemic has disrupted health systems around the world. The objectives of this study are to estimate the overall effect of the pandemic on essential health service use and outcomes in Mexico, describe observed and predicted trends in services over 24 months, and to estimate the number of visits lost through December 2020. METHODS: We used health information system data for January 2019 to December 2020 from the Mexican Institute of Social Security (IMSS), which provides health services for more than half of Mexico's population-65 million people. Our analysis includes nine indicators of service use and three outcome indicators for reproductive, maternal and child health and non-communicable disease services. We used an interrupted time series design and linear generalised estimating equation models to estimate the change in service use and outcomes from April to December 2020. Estimates were expressed using average marginal effects on the risk ratio scale. RESULTS: The study found that across nine health services, an estimated 8.74 million patient visits were lost in Mexico. This included a decline of over two thirds for breast and cervical cancer screenings (79% and 68%, respectively), over half for sick child visits and female contraceptive services, approximately one-third for childhood vaccinations, diabetes, hypertension and antenatal care consultations, and a decline of 10% for deliveries performed at IMSS. In terms of patient outcomes, the proportion of patients with diabetes and hypertension with controlled conditions declined by 22% and 17%, respectively. Caesarean section rate did not change. CONCLUSION: Significant disruptions in health services show that the pandemic has strained the resilience of the Mexican health system and calls for urgent efforts to resume essential services and plan for catching up on missed preventive care even as the COVID-19 crisis continues in Mexico.

Objective: To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres. Methods: We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data. Findings: On average across 56 countries, public hospitals were used as the sole source of care by 16.9% of 126 012 women who obtained contraceptives, 23.1% of 418 236 women who received routine antenatal care, 19.9% of 47 677 children with diarrhoea and 18.5% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received. Conclusion: As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.

BACKGROUND: As more countries progress towards malaria elimination, a better understanding of the most critical health system features for enabling and supporting malaria control and elimination is needed. METHODS: All available health systems data relevant for malaria control were collated from 23 online data repositories. Principal component analysis was used to create domain specific health system performance measures. Multiple regression model selection approaches were used to identify key health systems predictors of progress in malaria control in the 2000-2016 period among 105 countries. Additional analysis was performed within malaria burden groups. RESULTS: There was large heterogeneity in progress in malaria control in the 2000-2016 period. In univariate analysis, several health systems factors displayed a strong positive correlation with reductions in malaria burden between 2000 and 2016. In multivariable models, delivery of routine services and hospital capacity were strongly predictive of reductions in malaria cases, especially in high burden countries. In low-burden countries approaching elimination, primary health center density appeared negatively associated with progress while hospital capacity was positively correlated with eliminating malaria. CONCLUSIONS: The findings presented in this manuscript suggest that strengthening health systems can be an effective strategy for reducing malaria cases, especially in countries with high malaria burden. Potential returns appear particularly high in the area of service delivery.

BACKGROUND: Quality of care depends on system, facility, provider, and client-level factors. We aimed at examining structural and process quality of services for sick children and its association with client satisfaction at health facilities in Ethiopia. METHODS: Data from the Ethiopia Service Provision Assessment Plus (SPA+) survey 2014 were used. Measures of quality were assessed based on the Donabedian framework: structure, process, and outcome. A total of 1908 mothers or caretakers were interviewed and their child consultations were observed. Principal component analysis was used to construct quality of care indices including a structural composite score, a process composite score, and a client satisfaction score. Multilevel mixed linear regression was used to analyze the association between structural and process factors with client satisfaction. RESULT: Among children diagnosed with suspected pneumonia, respiratory rate was counted in 56% and temperature was checked in 77% of the cases. A majority of children (92%) diagnosed with fever had their temperature taken. Only 3% of children with fever were either referred or admitted, and 60% received antibiotics. Among children diagnosed with malaria, 51% were assessed for all three Integrated Management of Childhood Illnesses (IMCI) main symptoms, and 4% were assessed for all three general danger signs. Providers assessed dehydration in 54% of children with diarrhea with dehydration, 17% of these children were admitted or referred to another facility, and Oral Rehydration Solution was prescribed for 67% while none received intravenous fluids. The number of basic amenities in the facility was negatively associated with the clients' satisfaction. Private facilities, when the providers had got training for care of sick children in the past 2 years, had higher client satisfaction. There was no statistical association between structure, process composite indicators and client satisfaction. CONCLUSION: The assessment of sick children was of low quality, with many missing procedures when comparing with IMCI guidelines. In spite of this, most clients were satisfied with the services they received. Structural and process composite indicators were not associated with client's satisfaction. These findings highlight the need to assess other dimensions of quality of care besides structure and process that may influence client satisfaction.

BACKGROUND: The true burden of tuberculosis in children remains unknown, but approximately 65% go undetected each year. Guidelines for tuberculosis clinical decision-making are in place in Kenya, and the National Tuberculosis programme conducts several trainings on them yearly. By 2018, there were 183 GeneXpert® machines in Kenyan public hospitals. Despite these efforts, diagnostic tests are underused and there is observed under detection of tuberculosis in children. We describe the process of designing a contextually appropriate, theory-informed intervention to improve case detection of TB in children and implementation guided by the Behaviour Change Wheel. METHODS: We used an iterative process, going back and forth from quantitative and qualitative empiric data to reviewing literature, and applying the Behaviour Change Wheel guide. The key questions reflected on included (i) what is the problem we are trying to solve; (ii) what behaviours are we trying to change and in what way; (iii) what will it take to bring about desired change; (iv) what types of interventions are likely to bring about desired change; (v) what should be the specific intervention content and how should this be implemented? RESULTS: The following behaviour change intervention functions were identified as follows: (i) training: imparting practical skills; (ii) modelling: providing an example for people to aspire/imitate; (iii) persuasion: using communication to induce positive or negative feelings or stimulate action; (iv) environmental restructuring: changing the physical or social context; and (v) education: increasing knowledge or understanding. The process resulted in a multi-faceted intervention package composed of redesigning of child tuberculosis training; careful selection of champions; use of audit and feedback linked to group problem solving; and workflow restructuring with role specification. CONCLUSION: The intervention components were selected for their effectiveness (from literature), affordability, acceptability, and practicability and designed so that TB programme officers and hospital managers can be supported to implement them with relative ease, alongside their daily duties. This work contributes to the field of implementation science by utilising clear definitions and descriptions of underlying mechanisms of interventions that will guide others to do likewise in their settings for similar problems.

BACKGROUND: Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. METHODS AND FINDINGS: We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied. CONCLUSIONS: In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.

BACKGROUND: Despite the almost universal adoption of Integrated Management of Childhood Illness (IMCI) guidelines for the diagnosis and treatment of sick children under the age of five in low- and middle-income countries, child mortality remains high in many settings. One possible explanation of the continued high mortality burden is lack of compliance with diagnostic and treatment protocols. We test this hypothesis in a sample of children with severe illness in the Democratic Republic of the Congo (DRC). METHODS: One thousand one hundred eighty under-five clinical visits were observed across a regionally representative sample of 321 facilities in the DRC. Based on a detailed list of disease symptoms observed, patients with severe febrile disease (including malaria), severe pneumonia, and severe dehydration were identified. For all three disease categories, treatments were then compared to recommended case management following IMCI guidelines. RESULTS: Out of 1180 under-five consultations observed, 332 patients (28%) had signs of severe febrile disease, 189 patients (16%) had signs of severe pneumonia, and 19 patients (2%) had signs of severe dehydration. Overall, providers gave the IMCI-recommended treatment in 42% of cases of these three severe diseases. Less than 15% of children with severe disease were recommended to receive in-patient care either in the facility they visited or in a higher-level facility. CONCLUSIONS: These results suggest that adherence to IMCI protocols for severe disease remains remarkably low in the DRC. There is a critical need to identify and implement effective approaches for improving the quality of care for severely ill children in settings with high child mortality.

Background: Pneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi. Methods: Data were obtained from the 2013-2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity. Results: 3136 clinical visits for children 2-59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30% (SD 13%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23% in providers at the 75th percentile for guideline adherence compared with 14% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity. Conclusions: Care quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality.

BACKGROUND: While health care provider knowledge is a commonly used measure for process quality of care, evidence demonstrates that providers don't always perform as much as they know. We describe this know-do gap for malaria care for sick children among providers in Ethiopia and examine what may predict this gap. METHODS: We use a 2014 nationally-representative survey of Ethiopian providers that includes clinical knowledge vignettes of malaria care and observations of care provided to children in facilities. We compare knowledge and performance of assessment, treatment and counseling items and overall. We subtract performance scores from knowledge and use regression analysis to examine what facility and provider characteristics predict the gap. 512 providers that completed the malaria vignette and were observed providing care to sick children were included in the analysis. RESULTS: Vignette and observed performance were both low, with providers on average scoring 39% and 34% respectively. The know-do gap for assessment was only 1%, while the gap for treatment and counseling items was 39%. Doctors had the largest gap between knowledge and performance. Only provider type and availability of key equipment significantly predicted the know-do gap. CONCLUSIONS: While both provider knowledge and performance in sick child care are poor, there is a gap between knowledge and performance particularly with regard to treatment and counseling. Interventions to improve quality of care must address not only deficiencies in provider knowledge, but also the gap between knowledge and action.

The effect of HIV treatment on hospitalization rates for HIV-infected people has never been established. We quantified this effect in a rural South African community for the period 2009-13. We linked clinical data on HIV treatment start dates for more than 2,000 patients receiving care in the public-sector treatment program with five years of longitudinal data on self-reported hospitalizations from a community-based population cohort of more than 100,000 adults. Hospitalization rates peaked during the first year of treatment and were about five times higher, compared to hospitalization rates after four years on treatment. Earlier treatment initiation could save more than US$300,000 per 1,000 patients over the first four years of HIV treatment, freeing up scarce resources. Future studies on the cost-effectiveness of HIV treatment should include these effects.

OBJECTIVES: The nature of patient-provider interactions and communication is widely documented to significantly impact on patient experiences, treatment adherence and health outcomes. Yet little is known about the broader contextual factors and dynamics that shape patient-provider interactions in high HIV prevalence and limited-resource settings. Drawing on qualitative research from five sub-Saharan African countries, we seek to unpack local dynamics that serve to hinder or facilitate productive patient-provider interactions. METHODS: This qualitative study, conducted in Kisumu (Kenya), Kisesa (Tanzania), Manicaland (Zimbabwe), Karonga (Malawi) and uMkhanyakude (South Africa), draws upon 278 in-depth interviews with purposively sampled people living with HIV with different diagnosis and treatment histories, 29 family members of people who died due to HIV and 38 HIV healthcare workers. Data were collected using topic guides that explored patient testing and antiretroviral therapy treatment journeys. Thematic analysis was conducted, aided by NVivo V.8.0 software. RESULTS: Our analysis revealed an array of inter-related contextual factors and power dynamics shaping patient-provider interactions. These included (1) participants' perceptions of roles and identities of 'self' and 'other'; (2) conformity or resistance to the 'rules of HIV service engagement' and a 'patient-persona'; (3) the influence of significant others' views on service provision; and (4) resources in health services. We observed that these four factors/dynamics were located in the wider context of conceptualisations of power, autonomy and structure. CONCLUSION: Patient-provider interaction is complex, multidimensional and deeply embedded in wider social dynamics. Multiple contextual domains shape patient-provider interactions in the context of HIV in sub-Saharan Africa. Interventions to improve patient experiences and treatment adherence through enhanced interactions need to go beyond the existing focus on patient-provider communication strategies.