Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries

Abstract

Objective: Assess the quality of healthcare across African countries based on health providers' clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage.

Methods: With nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme.

Results: Across all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers' absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively.

Conclusion: Our findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers' absenteeism would only modestly increase the average care readiness that meets minimum quality standards.

Keywords: child health; health systems; health systems evaluation; maternal health.

Figure 1

Diagnostic and treatment accuracy. Dots represent country-specific means, calculated using country-specific sampling weights, vertical bars indicate mean performance across countries, and boxes delineate the interquartile range. Data are from clinical vignettes from Kenya (2018), Madagascar (2016), Mozambique (2014), Nigeria (2013), Niger (2017), Senegal (2010), Sierra Leone (2018) Tanzania (2016), Togo (2014) and Uganda (2013). The malaria vignette was not used in the Kenya (2018) survey and the postpartum haemorrhage, neonatal asphyxia and diabetes vignettes were not used in the Senegal (2010) survey.

Figure 2

Overprescription of antibiotics. Dots represent country-specific means, calculated using country-specific sampling weights, vertical bars indicate mean performance across countries and boxes delineate the interquartile range. Data are from clinical vignettes from Kenya (2018), Madagascar (2016), Mozambique (2014), Nigeria (2013), Niger (2017), Senegal (2010), Sierra Leone (2018) Tanzania (2016), Togo (2014) and Uganda (2013). See online supplemental appendix table S11 for the values in this figure.

Figure 3

Comparing estimates of minimum quality care (A) Plots the relationship between the estimated probability of care readiness that meets minimum quality standards for child, neonatal, and maternity care, verus the estimated probability of care readiness that meets minimum quality standards for child, neonatal, and maternity care assuming essential drugs treating the conditions are available. (B) Plots the relationship between the estimated probability of care readiness that meets minimum quality standards for child, neonatal, and maternity care, versus the estimated probability of care readiness that meets minimum quality standards for child, neonatal, and maternity care assuming no absenteeism. Child, neonatal and maternity care includes diarrhoea, pneumonia, postpartum haemorrhage and neonatal asphyxia. Essential drugs are oral rehydration salts for diarrhoea, antibiotics for pneumonia and oxytocin for postpartum haemorrhage. Data are from clinical vignettes, unannounced visits and visual inspections from Kenya (2018), Madagascar (2016), Mozambique (2014), Nigeria (2013), Niger (2017), Sierra Leone (2018), Tanzania (2016), Togo (2014) and Uganda (2013). ISO 3-digit alphabetic codes are: KEN (Kenya), MDG (Madagascar), MOZ (Mozambique), NER (Niger), NGA (Nigeria), SLE (Sierra Leone), TZA (Tanzania), TGO (Togo), UGA (Uganda).

Figure 4

Diagnostic and treatment accuracy across cadres. Share of providers among doctors, nurses, and community health workers correctly diagnosing the two main killer diseases for children (diarrhoea, pneumonia). The estimates are (unweighted) mean outcomes across countries, with the country means calculated using country-specific sampling weights. The error bars represent the 95% CI. Data are from clinical vignettes from Kenya (2018), Madagascar (2016), Mozambique (2014), Nigeria (2013), Niger (2017), Sierra Leone (2018) Tanzania (2016), Togo (2014) and Uganda (2013).