Facility infrastructure does not indicate healthcare quality in low/middle-income countries

While a strong infrastructure is important for healthcare, measures of health facility infrastructure are poorly correlated with health system quality, according to a new study published this week in PLOS Medicine by Hannah Leslie from the Harvard T.H. Chan School of Public Health, USA, and colleagues.

Improved quality of care is increasingly recognized as a necessary step toward better health outcomes in low- and middle-income countries. Current measurements of quality of care often center on structural inputs to care, including amenities and equipment. In the new study, researchers used health surveys conducted in eight countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania and Uganda. From the data, which included 35,531 observations of care in 4,354 facilities, they constructed indices of structural inputs and clinical quality related to family planning, antenatal care, sick-child care, and labor and delivery.

Overall, facilities had moderate levels of infrastructure ratings and low adherence to evidence-based guidelines. However, correlation between infrastructure and evidence-based care was low. Facilities with similar infrastructure ratings delivered widely varying quality of care. There was no minimum level of infrastructure that was reliably associated with higher quality of care in any area.

"As the quality of care assumes a more prominent role in national and global efforts to improve population health outcomes, accurate measurement is vital," the authors say. "Health care providers and physical inputs, such as building, medicines, and equipment are an essential foundation for delivering healthcare. However, we found that these structural measures provide little insight on the quality of services delivered to patients."

In an accompanying Perspective, Lars Persson of the London School of Hygiene & Tropical Medicine, UK, discusses the need for new measurements of quality of care in order to reach current goals in maternal, newborn, and child health. "So far the existing tools and information systems are not adequate for measuring quality of care," he writes. "Accurate measurements are needed that reflect the context, the processes of giving and receiving care, and the effects on the health status of patients and populations."