Print version ISSN 0042-9686
Bull World Health Organ vol.81 n.2 Genebra Jan. 2003
Quality and comparison of antenatal care in public and private providers in the United Republic of Tanzania
Qualité des soins pré natals : comparaison du rôle et des performances des prestateurs publics et privés dans une zone urbaine de Tanzanie
Comparación de la calidad de la atención prenatal entre proveedores públicos y privados en la República Unida de Tanzanía
Christoph BollerI; Kaspar WyssII; Deo MtasiwaIII; Marcel TannerIV
IScientific Collaborator, Swiss Centre for International Health, Swiss Tropical Institute, Basel, Switzerland
IIPublic Health Specialist, Swiss Centre for International Health, Swiss Tropical Institute, Basel, Switzerland
IIICity Medical Officer of Health, Ministry of Health, Dar es Salaam, United Republic of Tanzania
IVDirector, Swiss Tropical Institute, Basel, Switzerland
OBJECTIVE: To compare the quality of public and private first-tier antenatal care services in Dar es Salaam, United Republic of Tanzania, using defined criteria.
METHODS: Structural attributes of quality were assessed through a checklist, and process attributes, including interpersonal and technical aspects, through observation and exit interviews. A total of 16 health care providers, and 166 women in the public and 188 in the private sector, were selected by systematic random sampling for inclusion in the study. Quality was measured against national standards, and an overall score calculated for the different aspects to permit comparison.
FINDINGS: The results showed that both public and private providers were reasonably good with regard to the structural and interpersonal aspects of quality of care. However, both were poor when it came to technical aspects of quality. For example, guidelines for dispensing prophylactic drugs against anaemia or malaria were not respected, and diagnostic examinations for the assessment of gestation, anaemia, malaria or urine infection were frequently not performed. In all aspects, private providers were significantly better than public ones.
CONCLUSION: Approaches to improving quality of care should emerge progressively as a result of regular quality assessments. Changes should be introduced using an incremental approach addressing few improvements at a time, while ensuring participation in, and ownership of, every aspect of the strategy by health personnel, health planners and managers and also the community.
Keywords Prenatal care/standards/economics/organization and administration; Quality assurance, Health care; Quality of health care; Delivery of health care; Health personnel/standards; Urban health services; Public sector; Private sector; Socioeconomic factors; Comparative study; United Republic of Tanzania (source: MeSH, NLM).
OBJECTIF: Comparer au moyen de critères établis la qualité des services pré natals de premier niveau assurés par les secteurs public et privé dans lagglomération de Dar-es-Salaam, en République-Unie de Tanzanie.
MÉTHODES: On a évalué les caracté ristiques structurelles au moyen dune liste de contrô le, et les caracté ristiques de fonctionnement, qui englobent les aspects interpersonnels et techniques, par lobservation et en interrogeant les femmes à leur sortie des services. Lé tude, effectué e par sondage alé atoire systé matique, a porté sur 16 prestataires au total et sur 166 femmes dans le secteur public et 188 dans le secteur privé . On a comparé la qualité aux normes nationales et calculé un score global pour les diffé rents aspects afin de faire des comparaisons.
RÉSULTATS: Les ré sultats montrent que, dans le public comme dans le privé , la qualité des soins est assez bonne en ce qui concerne les aspects structurels et interpersonnels. Elle est toutefois mé diocre dans les deux secteurs pour les aspects techniques. Cest ainsi que les directives concernant ladministration dune prophylaxie antiané mique ou antipaludique ne sont pas respecté es et que, souvent, les examens pour dé terminer lâge gestationnel et dé pister lané mie, le paludisme ou une infection urinaire ne sont pas effectué s. Pour tous les aspects, la qualité est significativement meilleure dans le privé que dans le public.
CONCLUSION: Des é tudes ré guliè res de la qualité devraient progressivement dé boucher sur des approches permettant damé liorer la qualité des soins. Il faut adopter une dé marche graduelle en ne changeant que quelques aspects à la fois et en veillant à associer pleinement le personnel de santé, les planificateurs sanitaires, les administrateurs et la communauté à tous les aspects de la stratégie.
Mots clés Soins prénatals/normes/économie/organisation et administration; Garantie qualité soins; Qualité soins; Délivrance soins; Personnel sanitaire/normes; Services santé milieu urbain; Secteur public; Secteur privé; Facteurs économiques; Etude comparative; République-Unie de Tanzanie (source: MeSH, INSERM).
OBJETIVO: Comparar la calidad de los servicios públicos y privados de atención prenatal de primer nivel en Dar es Salaam, República Unida de Tanzanía, usando criterios previamente definidos.
MÉTODOS: Los pará metros estructurales definitorios de la calidad se evaluaron mediante una lista de verificación, y los relativos al proceso, incluidos los aspectos interpersonales y técnicos, mediante observación y entrevistasa la salida.Se seleccionó para el estudio, mediante muestreo aleatorio sistemático, a un total de 16 proveedores de atención sanitaria y a 166 mujeres en el sector público y 188 en el privado. La calidad se determinó por referencia a la norma nacional, obtenié ndose una puntuación general para los diferentes aspectos con fines comparativos.
RESULTADOS: Los resultados indican que los proveedores de los servicios, tanto públicos como privados, actuaron de forma razonablemente satisfactoria en lo que atañe a los aspectos estructurales e interpersonales de la calidad de la atención. Sin embargo, unos y otros mostraron un nivel insuficiente por lo que se refiere a los aspectos té cnicos de la calidad. Por ejemplo, no se respetaron las directrices elaboradas para dispensar medicamentos profilácticos contra la anemia o el paludismo, y con frecuencia no se realizaron exámenes diagnósticos de evaluación del embarazo, la anemia, el paludismo o las infecciones urinarias. En todos los aspectos, los proveedores privados fueron significativamente mejores que los públicos.
CONCLUSIÓN: Las medidas de mejora de la calidad de la atención deben ser el resultado progresivo de evaluaciones regulares de la calidad. Los cambios se deben introducir aplicando un enfoque gradual que aborde pocas mejoras a la vez, sin dejar de asegurar la participación, y también la adhesión, del personal de salud y los planificadores y gerentes sanitarios, así como de la comunidad, en todos los aspectos de la estrategia.
Palabras clave Atención prenatal/normas/economía/organización y administración; Garantía de la calidad de atención de salud; Calidad de la atención de salud; Prestación de atención de salud; Personal de salud/normas; Servicios urbanos de salud; Sector público; Sector privado; Factores socioeconómicos; Estudio comparativo; República Unida de Tanzanía (fuente: DeCS, BIREME).
In recent years, many developing countries have been actively seeking to improve the outputs and outcomes of their health care delivery system by engaging in a process of reform. Important elements of health sector reform in the United Republic of Tanzania have been the promotion of the private sector and improvements in the quality of care delivered by both private and public providers (1). Private services can clearly fill gaps when public services are inadequate, but there is a need to assess the quality of the care that they are providing as there is often concern about their performance (24).
One study in Dar es Salaam in the early 1990s (5) judged that the quality of curative outpatient care offered by governmental and private providers was low. Private facilities as a whole performed better than government ones, but many of them carried out practices that did not fulfil the norms established by the government. Subsequently, substantial efforts were made to improve the quality of care in the public sector through the Dar es Salaam Urban Health Project; for example by upgrading the equipment of first-tier facilities, making drugs regularly available, and training health workers.
Quality can be assessed from the point of view of the users (perceived quality) or by using technical standards (quality defined by professionals). Donabedian (68) was one of the first to reflect upon quality, to operationalize the term, and to offer a framework for its definition based on three major attributes: structure, process, and outcome. "Structure" refers to the attributes of the settings where health care occurs (material, human and financial resources, and organizational structure); "process" denotes what is actually done in giving and receiving care; and "outcome" indicates the effects of care on the health status of patients and populations (morbidity and mortality levels). Most studies assessing quality of care have looked at curative services and at structural aspects and process attributes (911), at client satisfaction (12, 13), or at the relation between curative and preventive services (14).
The present study, carried out in Dar es Salaam in 1999, compared the quality of antenatal care offered by public and private providers at the first-tier level.
Study area and sampling
Dar es Salaam is the largest city in the United Republic of Tanzania and at the time of the study, in 1999, had around 2.5 million inhabitants. Private profit-making health services have been operating in Dar es Salaam since the early 1990s, and in 1999 there were more than 500 private clinics and hospitals, ranging from small clinics to referral hospitals offering relatively high-technology services such as ultrasonography. In the government regulations a distinction is made between private profit-making and voluntary sectors. Delineation between these categories is, however, difficult (5), and so this paper makes no further distinction between these different types of private providers.
Selection of the health facilities to be included in the study was based on the Tanzanian Health Management Information System. Selected providers had to satisfy the following criteria: offer mother and child health care (MCH) services; be first-tier facilities (district and referral hospitals of both private and public sectors were excluded); and have a minimum of ten daily attendances. Based on these criteria, 18 facilities in the public and 19 in the private sector qualified for inclusion. From these, eight were initially randomly chosen for each sector. Data were collected over two days, and all pregnant women attending were included. One public first-tier service was excluded since no woman attended it during the data-collection days. For the private sector, an additional provider was included in the sample because the attendance rate was low at one of the other private providers. The sample thus consisted of seven public-service and nine private-sector providers. A total of 166 women who attended the public facilities were interviewed and observed, and 188 who attended private ones.
Operational definition of quality of care, data collection and analysis
This study used a definition of quality of care based on the framework provided by Donabedian (7, 8). Since outcome is a consequence of care rather than a component of quality of care (15), it was not further assessed. The main focus was therefore on process attributes of quality, particularly provider-client interaction. Interpersonal conduct and technical aspects were considered separately. The definition of adequate or good quality was based on local standards (16, 17). Benchmarks formulated for inputs, laboratory examination and prophylactic and treatment approaches during antenatal care were critically reviewed and transposed into measurable elements each describing an attribute. As carried out in a similar study on structural aspects of quality of care (18), individual elements were weighted based on a professional judgement on what can be considered as a good medical or behavioural standard. Points were then allocated to these characteristics, which in turn allowed calculation of an overall score for each of the attributes.
Structural attributes of quality were assessed using a checklist based on various characteristics (Table 1). The process dimension was measured through observation of the patient-provider interaction, considering interpersonal and technical aspects separately. Judgement of interpersonal quality was based on the accommodation provided for the women, privacy during the consultation, and the interaction between the client and provider. Technical aspects of process attributes were assessed by observing history taking, physical examination, diagnostic approach, prescription of prophylactic treatments, and provision of health education.
A socioeconomic ranking was constructed with the help of a points system. A score was assigned to the household to which the women belonged. The composite revenue score was based on the housing situation of the woman's household: the number of rooms available and the level of crowding; the construction of the house; the availability of basic infrastructure (water, electricity); and ownership of means of transportation and household goods (refrigerator, television, radio). Scores between 0 and 3 were assigned for each of these characteristics and a total score between 0 and 30 was assigned to each woman's household.
Data was collected over the period JuneAugust 1999 by two female fieldworkers. Data were entered and analysed using EpiInfo 6.04 software (Centers for Disease Control and Prevention, Atlanta, GA, USA). Logical checks helped to ensure the accuracy of data entry. Differences between the public and private sectors in the overall scores were compared using the KruskalWallis test, a non-parametric test for independent samples.
Obstetrical and socioeconomic characteristics of women attending antenatal care services
The median age of the study women was 25 years, 9% being under 18 years of age, and 8% over 33 years of age. For 31% of the women it was their first pregnancy. For 12% of women the observation and exit interview were performed during their first visit to a health service, and for 17% during the second visit. The remaining women were attending for their third or a further visit. No significant differences in the obstetrical characteristics were found between women attending public or private providers.
Socioeconomic conditions of a household may well influence health-seeking behaviour (19, 20). The results indicated that the use of antenatal care services by a pregnant woman was related to the socioeconomic status of her household: women living in worse conditions consulted private health services less often and relied more often on governmental health service than those living in better circumstances. Women attending public sector facilities had a median socioeconomic score of 11 (range, 525) (see Fig. 1). Women who attended consultations in the private sector had a median score of 13 (range 726) out of a maximum of 31 points. Differences were significant (H = 20.6; P < 0.001).
Fees charged for antenatal care
Iron(II) sulfate and folic acid (FeFo) for anaemia prophylaxis were provided free to 72% of the women attending governmental services. In the private sector only 12% of women received FeFo free. If available, chloroquine was distributed without charge by public services, while 93% of women using private services had to pay for it. In the private sector all the women had to pay for registration and laboratory examinations, while in the public services, 79% of women attending had to pay for registration and 88% for diagnostic services. Pregnant women using private services not only had to pay more often than in the public sector, but the median charge per consultation was about six times higher (910 Tanzanian shillings (US$ 1.3)) than in the public sector (140 Tanzanian shillings (US$ 0.2)).
Structural attributes of quality
The physical infrastructure of all first-tier public and private facilities was reasonably good (Table 2). Maintenance was generally better in private facilities. Regarding basic diagnostic tools, equipment was clearly better in the private sector. The median overall score for structural attributes of quality, out of a maximum of 72, was 51 (range 3554) for the public and 64 (range 5672) for the private sector. These differences were significant (H = 11.2; P <0.001) (>Fig. 2).
Process attributes of care: interpersonal aspects
In all consultation rooms in both public and private facilities there were seats available, and these were offered to 89% of the women attending public facilities and to 93% in private ones (Table 3). Privacy of the consultation (i.e., the door of the examination room being closed) was observed in 81% of consultations in the public sector and in 99% in the private sector. Women were invited to talk about their medical concerns in 71% of consultations in public facilities and 81% in private ones. Diagnoses of anaemia, malaria, or other pregnancy-related conditions were made for 54% of women both in the private and in the public sector. In general, interpersonal aspects of quality were good, especially in relation to welcoming the patient and providing privacy for the consultation. The median summary score for interpersonal aspects was higher for the private sector, where it was 13 (range 416) whereas for the public sector it was 11 (range 516), out of a maximum of 16. This difference was significant (H =1 3.4; P <0.001) (>Fig. 3).
Process attributes: technical aspects
The general history of the pregnant women was taken in 35% of all consultations in the public sector and in 49% in the private sector (Table 4). Questions about recent malaria episodes, urinary tract infections, or signs of anaemia were hardly ever asked by the health personnel. The frequency of carrying out specific physical examinations revealed a heterogeneous picture. Some of the examinations were done very regularly (weighing, auscultation of the fetal heart, and palpation of the fundus). Others were done less regularly, for example haemoglobin measurement and looking for clinical signs of anaemia by checking for pale mucous membranes or conjunctiva. The median score for technical aspects of quality of care was 18 (range 528) in the public sector and 21 (range 1033) in the private sector out of a maximum of 39. The differences were significant (H = 62.5; P <0.001) (>Fig. 4). Although quality was somewhat better in the private sector, the overall performance was considered weak in both sectors. For example, routine prophylaxis for well-known pregnancy-related risk factors such as malaria or anaemia was only prescribed in a small proportion of consultations, and albumin checks were made in less than half of the consultations.
Qualifications of the personnel and consultation time
The training levels of the personnel working in the antenatal care services in the public and the private sector differed, with those working in the latter having higher qualifications. In the public sector nearly all consultations (88%) were performed by an MCH auxiliary (who has two years' training) and virtually none by a doctor. In the private sector 10% of consultations were carried out by a doctor or an assistant medical officer, 60% by a midwife or nurse, and only 30% by an MCH auxiliary. There was a clear relation between the qualifications of the staff and the quality of the service provided. The more highly trained personnel performed better in the technical aspects of quality, with the doctors and medical assistants carrying out investigations more often, such as checking the urine or controlling for oedema (results not shown).
In general, consultation times were short. One-fifth of the consultations lasted less than 4 min, one-half less than 6 min, and 81% less than 10 min. There was a relation between consultation time and the qualifications of the personnel; medical doctors and assistant medical doctors spent an average of 14 min on a consultation, twice as long as midwives, nurses and MCH auxiliaries. On the other hand, there was no relation between the duration of the consultation and the number of women going to a particular provider each day.
The present study indicated that the women visiting private facilities for antenatal care were socioeconomically better off than those using public ones and that they generally paid more for the services. Some women attending public services reported that usually they had to pay for all services, including prophylaxis and blood pressure measurements, but that on the day of the interview services were free. This indicates that the presence of interviewers introduced a bias and that the estimates in the public sector for the cost study were too low. A similar observation was made in Uganda (21). However, even if the cost of public services was underestimated, the cost of attending private antenatal care facilities is still higher.
The study showed that structural attributes of quality were generally satisfactory, and that they had improved in public facilities considerably since the early 1990s as a result of rehabilitation and a better availability of drugs. Both private and public facilities provided a reasonably good quality of care in terms of interpersonal aspects. The assessment of the quality of first-tier antenatal care services, based on Tanzanian national standards, has shown that neither public nor private providers are offering an adequate quality of care from the technical point of view, although private providers are performing better. Instructions given in official guidelines, for example concerning the dispensing of prophylactic drugs against anaemia or malaria, were not respected or diagnostic examinations were frequently not carried out. It is possible, however, that the process dimensions of quality of care were affected partially by measurement bias. Although observations by fieldworkers were made as discretely as possible and staff did not know in advance that the fieldworkers would visit, their presence possibly influenced the behaviour of health workers. For example, women might have been treated more courteously than usual. If so, general judgements on interpersonal and technical quality would be higher than under normal conditions. However, there is no reason to believe that this bias would alter the conclusions of the study with regard to process attributes of quality, nor the comparisons between the private and public sector.
Various authors have formulated concern about the quality of care provided by the private sector, and low quality treatment practices have been reported for various diseases (22, 23). This study pointed out that private providers for antenatal care were significantly better than public ones with regard to all attributes of quality under investigation. This is in line with other studies which have showed that private services can deliver adequate services in family planning or treatment of sexually transmitted diseases (24, 25).
There has been rapid growth in the private sector since new legislation on individual medical practice was introduced at the beginning of the 1990s. As a result, public providers increasingly have to compete for patients by offering services of adequate quality. Today, private health facilities account for more than 85% of health facilities in the city, and provide curative care for a majority of the population (20). Regulating and improving quality of care in the private sector presents an additional challenge in an already complex and difficult endeavour. Legislation on minimum standards is needed, as well as adequate public supervision to ensure its enforcement (26). However, such measures need to be accompanied by education and information campaigns to make sure that all those working in the private sector understand the minimum standards required. Education of clients about what minimum standards they should expect in return for the fees they pay could also play a role in influencing the private sector.
Quality of care is closely linked to the quality of the health services personnel. The study showed that the quality of performance was linked to the training level of the personnel (see also 9, 10). The fact that in the private sector staff were better qualified was one reason why quality was judged to be better in this sector. However, most first-tier services will continue to be provided by less well-qualified staff, particularly in the public sector. The reasons why health workers perform badly need to be investigated, and ways found to improve their performance. It needs to be established whether the problem is lack of knowledge, or whether workers are not able to translate knowledge into appropriate practices.
Approaches to improving quality of care should be based on regular quality assessments and additional operational research activities. The following are important components of such strategies (27): using an incremental approach introducing a few issues at a time and revisiting them regularly; and ensuring participation, choice, and ownership of every aspect of the strategy, while at the same time providing vision and direction. The latter component implies involving health staff at all levels of the health care system, as well as the community, through an active dialogue and sharing of decision making. The ultimate goal should then be "to create an environment of watchful concern that motivates everybody to perform better" (6).
We are very grateful to the women and health workers who kindly agreed to participate in the study. We would like to thank Jennifer Jenkins and Guy Hutton for advice and helpful comments during the writing of the document. The Swiss Federal Office of Education and Science provided financial assistance for this research through its contribution to the European Union funded Concerted Action "Improving efficiency and quality of health networks in urban areas" (ERB IC18-CT98-0338). The Swiss Agency for Development and Co-operation (SDC) and the Swiss National Science Foundation (SNSF) gave additional financial support for the study through the Dar es Salaam Urban Health Project (DUHP) and through the Individual Project 4 (IP4) of the NCCR North-South: Research Partnerships for Mitigating Syndromes of Global Change.
Conflicts of interest: none declared.
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