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Measuring Quality of Care in Tanzania- Peter Binyaruka

This presentation was given at the pay-for-performance workshop in Tanzania, November 2015.

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Measuring Quality of Care in Tanzania- Peter Binyaruka

  1. 1. Measuring Quality of Care in Tanzania Peter Binyaruka Nov, 2015
  2. 2. Introduction Definition of quality of care (QoC) According to Donabedian framework, there are 3 domains: Donabedian, A. (1988) Domain Content Structure Facility environment, equipment, drugs, staffs, etc Process Actions during healthcare • Technical –content of care • Experience of care –interpersonal, satisfaction Outcome Changes in health status
  3. 3. Qns. on structural factors • What are the relevant factors? • How to measure those factors? • Binary, likert scale, etc • Subgroups of attributes –eg. groups of related drugs • On medical commodities –availability vs. stock-outs • Which composite measure to use? • Index –weighted vs. unweighted • Factor score –via factor analysis, etc
  4. 4. Structural factors considered in P4P -TZ Factors that affect the context in which care is delivered 1. Drugs o Antimalarial drugs (6) o Drugs during delivery care (3) o ART drugs (8) 2. Vaccines (5) 3. Medical supplies (11) 4. Equipment (19) 5. Facility infrastructure o Clean water availability o Electricity availability 6. Staffing level
  5. 5. Generating an index • Using different items/ questions to create an index • Composite score (index) solves the dimensionality problem with many items Index computation (unweighted) o For each question as binary –[Yes=1/No=0] response o For availability or stock-out o Aggregated to get the total Total=(∑responses) o Divided the total by number of items to get the index Index=[(∑responses)/n]
  6. 6. Results (1): P4P effects on structural QoC (TZ)Variables Baseline (%) Intervention arm Baseline (%) Control arm Difference Diff-in-diff, effect All drugs (27 items) Stock out 54 46 8* -17*** Availability 39 44 -5* 13*** Delivery care drugs Stock out 56 39 17*** -29*** Availability 43 45 -2 15*** Antimalarials Stock out 42 40 2 -12** Availability 60 69 -9** 20*** Vaccines (5) Stock out 17 13 4 -10* Availability 95 93 2 5 ART drugs (8) Stock out 54 51 3 -7 Availability 42 32 9 -3 Equipment (19) Functioning 57 55 2 3 Availability 58 60 -2 2 Medical supplies (11) Stock out 39 26 13*** -15*** Availability 57 54 3 -3
  7. 7. Results (2): P4P effects on structural QoC (TZ) Variables Baseline (%) Intervention arm Baseline (%) Control arm Differenc e Diff-in-diff, effect Staffing levels by cadre         Clinicians (number) 3.1 2.7 0.4 1.4 Nurses (number) 6.0 4.1 1.9 0.4 Paramedics (number) 4.7 4.4 0.3 1.8* Total staff (number) 13.7 11.2 2.5 2.8 Facility infrastructure         Electricity (%) 69.0 70.1 -1.1 0.2** Clean water (%) 73.3 79.5 -6.1 0.1
  8. 8. Structure measures
 “pros and cons” Pros • It can affect significantly the QoC provision • Provides a key picture of providers’ capacity • Often easy to observe and measure • Measure of service delivery readiness Cons • Lack of specificity –i.e. Having a capacity and actual use of that capacity • Unclear link between structure and process/outcome quality ✓ Often very complex and weak (Landon et al, 1998, 2001) •
  9. 9. Conclusions ▪ Structural aspect is one dimension in measuring QoC ▪ It has various pros and cons ▪ It is important –but other aspects should complement ▪ Need for evidence on the linkage (structure, process, outcome) Method, ▪ Use of a composite score/ index solves the dimensionality problem ▪ But, various method for generating an index should be used In Tanzania, ▪ P4P improved drug availability & lowering stock-outs ▪ Lowered vaccines & medical supplies stock-outs (but not availability) ▪ Improved electricity coverage ▪ But, no effect on ART, Equipment, and staffing level
  10. 10. 
 
 
 
 Thank you..!!
  11. 11. References • Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA, 260(12), 1743- 1748. • Landon et al (1998). A conceptual model of the effects of health care organizations on the quality of medical care. JAMA, 279(17), 1377-1382. • Landon et al (2001). Health plan characteristics and consumers' assessments of quality. Health Affairs, 20(2), 274-286.

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