Improving quality through cost recovery in Niger

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

The impact of user fees on access to health services in low- and middle-income countries

BACKGROUND

Following an international push for financing reforms, many low- and middle-income countries introduced user fees to raise additional revenue for health systems. User fees are charges levied at the point of use and are supposed to help reduce 'frivolous' consumption of health services, increase quality of services available and, as a result, increase utilisation of services.

OBJECTIVES

To assess the effectiveness of introducing, removing or changing user fees to improve access to care in low-and middle-income countries

SEARCH STRATEGY

We searched 25 international databases, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Trials Register, CENTRAL, MEDLINE and EMBASE. We also searched the websites and online resources of international agencies, organisations and universities to find relevant grey literature. We conducted the original searches between November 2005 and April 2006 and the updated search in CENTRAL (DVD-ROM 2011, Issue 1); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (January 25, 2011); MEDLINE, Ovid (1948 to January Week 2 2011); EMBASE, Ovid (1980 to 2011 Week 03) and EconLit, CSA Illumina (1969 - present) on the 26th of January 2011.

SELECTION CRITERIA

We included randomised controlled trials, interrupted time-series studies and controlled before-and-after studies that reported an objective measure of at least one of the following outcomes: healthcare utilisation, health expenditures, or health outcomes.

DATA COLLECTION AND ANALYSIS

We re-analysed studies with longitudinal data. We computed price elasticities of demand for health services in controlled before-and-after studies as a standardised measure. Due to the diversity of contexts and outcome measures, we did not perform meta-analysis. Instead, we undertook a narrative summary of evidence.

MAIN RESULTS

We included 16 studies out of the 243 identified. Most of the included studies showed methodological weaknesses that hamper the strength and reliability of their findings. When fees were introduced or increased, we found the use of health services decreased significantly in most studies. Two studies found increases in health service use when quality improvements were introduced at the same time as user fees. However, these studies have a high risk of bias. We found no evidence of effects on health outcomes or health expenditure.

AUTHORS' CONCLUSIONS

The review suggests that reducing or removing user fees increases the utilisation of certain healthcare services. However, emerging evidence suggests that such a change may have unintended consequences on utilisation of preventive services and service quality. The review also found that introducing or increasing fees can have a negative impact on health services utilisation, although some evidence suggests that when implemented with quality improvements these interventions could be beneficial. Most of the included studies suffered from important methodological weaknesses. More rigorous research is needed to inform debates on the desirability and effects of user fees.

The role of quality improvement in strengthening health systems in developing countries

Quality of care was recognized as a key element for improved health outcomes and efficiency in the World Health Organization's (WHO) widely adopted framework for health system strengthening in resource-poor countries. Although modern approaches to improving quality are increasingly used globally, their adoption remains sporadic in developing countries. Healthcare leaders and improvement experts representing 15 countries met in October 2008 to catalyze the adoption of quality improvement (QI) methods to improve healthcare quality in resource-poor settings. This paper describes the evidence used to frame deliberations, the proceedings and a proposal for incorporating QI methods into plans for strengthening health systems. The conference participants presented case reports and reviewed a growing body of evidence from peer-reviewed journals demonstrating that QI methods can make significant contributions in resource poor settings. Deliberations focused on the barriers to adoption of QI methods and potential strategies for addressing those barriers. Attendees concluded that QI has the potential to optimize the use of limited resources available from governments and global initiatives targeted at achieving shared aims. Demonstrable improvements in quality may encourage greater investment in health systems in developing countries by increasing donor, population and governmental confidence that resources are being used well.

Key quality aspect: a fundamental step for quality improvement in a resource-poor setting

The objective of the study is to identify user's perception of key quality aspects of the hospital and its influence on willingness to pay. The study was conducted in 2001 in Dhading District Hospital, Nepal. This was a descriptive, cross-sectional study design using quantitative and qualitative methods: questionnaire exit interview and focus group discussions with inpatients and outpatients, focus group discussion with service providers, and key informant interviews. The research identified attitude, technical and interpersonal skills of health personnel, availability of drugs and services as important quality aspects to be improved. Users were motivated to use this hospital and were ready to pay if they received proper treatment from skilled and communicative staff. This study highlights the importance of identifying the quality factors important to service users as a first step in improving quality. For the users within this study, this meant improving attitude, interpersonal skills, and technical skills of service personnel.

Maintaining quality of health services after abolition of user fees: a Uganda case study

Background

It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1^st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.

Methods

A population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.

Results

Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.

Conclusion

The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.

Demand assessment and price-elasticity estimation of quality-improved primary health care in Palestine: a contribution from the contingent valuation method

This paper proposes a new methodology to assess demand and price-elasticity for health care, based on patients' stated willingness to pay (WTP) values for certain aspects of health care quality improvements. A conceptual analysis of how respondents consider contingent valuation (CV) questions allowed us to specify a probability density function of stated WTP values, and consequently, to model a demand function for quality-improved health care, using a parametric survival approach. The model was empirically estimated using a CV study intended to assess patients' values for improving the quality of primary health care (PHC) services in Palestine. A random sample of 499 individuals was interviewed following medical consultation in four PHC centers. Quality was assessed using a multi-attribute approach; and respondents valued seven specific quality improvements using a decomposed valuation scenario and a payment card elicitation technique. Our results suggest an inelastic demand at low user fees levels, and when the price-increase is accompanied with substantial quality-improvements. Nevertheless, demand becomes more and more elastic if user fees continue to rise. On the other hand, patients' reactions to price-increase turn out to depend on their level of income. Our results can be used to design successful health care financing strategies that include a consideration of patients' preferences and financial capacities.

Impoverishment and patients' "willingness" and "ability" to pay for improving the quality of health care in Palestine: an assessment using the contingent valuation method

This paper examines the impact of impoverishment on patients' preferences with respect to improving the quality of health care, by focusing on the sudden impoverishment experience that affected the Occupied Palestinian Territory (OPT) since the beginning of the second Palestinian Uprising of September 2000. Two random samples of patients (352 and 353 individuals, respectively) were interviewed about their willingness to pay for improving a set of quality attributes in delivery of primary health care, prior and after the occurrence of this crisis situation, using a contingent valuation questionnaire. Impoverishment did not seem to affect the structure of patients' preferences vis-à-vis some essential quality attributes such as "doctor-patient relationship" and "drug availability". However, preferences toward "luxury" quality attributes, e.g., "geographical proximity" and "waiting time", suffered from both income-dependent and income-independent negative impoverishment effects. We conclude that impoverishment might not only affect individuals' availability of resources but also the ability of certain groups of patients, notably women, villagers and the elderly, to adequately express their preferences toward improving the quality of health care delivery. The issue of how willingness to pay results should be interpreted in the light of our study for policy implications was discussed. The study raises strong doubts about the current policy of introducing patients' cost recovery schemes for funding primary health care in the current crisis situation of the OPT.

User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes

User-fee programs have been introduced at health care facilities in many developing countries. Difficulties have been encountered, however, especially at public hospitals. This report describes the effects of user fees introduced in April 1997 at a public hospital, the National Maternal and Child Health Center (NMCHC) of Cambodia, on patient utilization, revenue and expenditure, quality of hospital services, provider attitudes, low-income patients, and the government, by reviewing hospital data, patient and provider surveys, and provider focus group discussions.Before the introduction of user fees, the revenue from patients was taken directly by individual staff as their private income to compensate their low income. After the introduction of user fees, however, revenue was retained by the hospital, and used to improve the quality of hospital services. Consequently, the patient satisfaction rate for the user-fee system showed 92.7%, and the number of outpatients doubled. The average monthly number of delivery of babies increased significantly from 319 before introduction of the system to 585 in the third year after the user-fee introduction, and the bed occupancy rate also increased from 50.6% to 69.7% during the same period. As patient utilization increased, hospital revenue increased. The generated revenue was used to accelerate quality improvement further, to provide staff with additional fee incentives that compensated their low government salaries, and to expand hospital services. Thus, the revenue obtained user fees created a benign cycle for sustainability at NMCHC. Through this process, the user-fee revenue offered payment exemption to low-income users, supported the government financially through user-fee contributions, and reduced financial support from donors. Although the staff satisfaction rate remained at 41.2% due to low salary compensation in the third year of user-fee implementation, staff's work attitude shifted from salary-oriented to patient-oriented-with more attention to low-income users.

Quality of care and the demand for health services in Bamako, Mali: the specific roles of structural, process, and outcome components

The public finance and foreign exchange crisis of the 1980s aggravated the unfavourable economic trends in many developing countries and resulted in budget cuts in the health sector. Policymakers, following the suggestions of World Bank experts, introduced user fees. Economic analysis of the demand for health care in these countries focused on the impact of price and income on health service utilisation. But the lesson to date from experiences in cost recovery is that without visible and fairly immediate improvements in the quality of care, the implementation of user fees will cause service utilisation to drop. For this reason, the role of quality of health care has been recently a subject of investigation in a number of health care demand studies. In spite of using the data from both households and facilities, recent studies are quite limited because they measure quality only by structural attributes (availability of drugs, equipment, number and qualifications of staff, and so on). Structural attributes of quality are necessary but not sufficient conditions for demand. A unique feature of this study is that it also considers the processes followed by practitioners and the outcome of care, to determine simultaneously the respective influence of price and quality on decision making. A nested multinomial logit was used to examine the choice between six alternatives (self-treatment, modern treatment at home, public hospital, public dispensary, for-profit facility and non-profit facility). The estimations are based on data from a statistically representative sample of 1104 patients from 1191 households and the data from a stratified random sample of 42 out of 84 facilities identified. The results indicate that omitting the process quality variables from the demand model produces a bias not only in the estimated coefficient of the "price" variable but also in coefficients of some structural attributes of the quality. The simulations suggest that price has a minor effect on utilisation of health services, and that health authorities can simultaneously double user fees and increase utilisation by emphasising improvement of both the structural and process quality of care in public health facilities.

Private pharmacies in Hanoi, Vietnam: a randomized trial of a 2-year multi-component intervention on knowledge and stated practice regarding ARI, STD and antibiotic/steroid requests

OBJECTIVES

To assess the effectiveness of a multi-component intervention on knowledge and reported practice amongst staff working in private pharmacies in Hanoi regarding four conditions: urethral discharge [sexually transmitted diseases (STD)], acute respiratory infection (ARI), and non-prescription requests for antibiotics and steroids.

METHOD

Randomized controlled trial with staff working in 22 matched pair intervention and control private pharmacies who were administered a semistructured questionnaire on the four conditions before and 4 months after the interventions. The interventions focused on the four conditions and were in sequence (i) regulations enforcement; (ii) face-to-face education and (iii) peer influence. Outcome measures were knowledge and reported change in practice for correct management of tracer conditions.

RESULTS

The intervention/control-pairs (22 after drop-outs) were analysed pre- and post-intervention using the Wilcoxon signed rank test. STD: More drug sellers stated they would ask about the health of the partner (P = 0.03) and more said they would advise condom use (P = 0.01) and partner notification (P = 0.04). ARI: More drug sellers stated they would ask questions regarding fever (P = 0.01), fewer would give antibiotics (P = 0.02) and more would give traditional medicines (P = 0.03). Antibiotics request: Fewer said they would sell a few capsules of cefalexin without a prescription (P = 0.02). Steroid requests: No statistical difference was seen in the numbers who said they would sell steroids without a prescription as numbers declined in both intervention and control groups (P = 0.12).

CONCLUSION

The three interventions in series over 17 months were effective in changing the knowledge and reported practice of drug sellers in Hanoi.

Ethical foundations of client-centered care in family planning

Biomedical ethics provides the foundation for a model of client-centered care that can assure the good quality of family planning and other reproductive health services in developed and developing countries. Client concerns mirror the four ethical principles of autonomy, justice, beneficence, and nonmaleficence. Autonomy reflects clients' desire for full information and respect from providers so that they can exercise their right to make their own informed decisions. Justice, for clients, means fair treatment and ready access to services, regardless of one's socioeconomic status, education, ethnic group, or residence. Beneficence means that providers possess the technical competence and understanding needed to act in the best interest of their clients, as clients expect. Nonmaleficence translates into client concerns about safety--that no harm will come to them as a result of seeking services. Putting these ethical principles into practice requires changing providers' attitudes from paternalistic to client centered. Assessments of client satisfaction can help family planning programs identify and respond to client values and even raise client expectations about the care they should receive. Managers also can contribute to good quality care by meeting providers' professional needs for training, supervision, supplies, record keeping, and so on. Family planning programs around the world are focusing on these ethical concerns to emphasize respect for client values, appropriate decision making, broader access to services, and basic safety issues. Although they use a variety of techniques, all these quality assurance and improvement initiatives share an ethically based, client-centered philosophy.