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Thousand. Before sharing sensitive information, make sure you're on a federal government site. School of Hygiene & of Tropical Medicine, Keppel Street, London, WC1E 7HT, England. Policies to improve the health of the population have often focused exclusively on expanding access to basic health services, neglecting the quality of care. Efforts to increase demand for priority interventions have implicitly assumed that the available care is of sufficient quality or that, with the expansion of coverage, the quality will naturally improve.
1 However, these assumptions may be wrong. There is increasing recognition that people can act in a perfectly rational way when they avoid using poor quality health services and that poor quality of care can be an obstacle to universal health coverage, regardless of access, 2.The objective of many strategies to improve the quality of health care has been to ensure that essential inputs, for example,. We have technology, operational facilities, pharmaceutical supplies, and trained health workers. 3.Many of these strategies have focused on the supply side and have been designed to support service delivery in accordance with clinical guidelines.
4.The recognition that quality improvement approaches should be applied in patient-centered care models is relatively recent. 5 In this article, we seek to analyze the complexities surrounding the quality of care and identify strategies to improve the measurement of that quality. Understanding these issues could inform pragmatic strategies for analyzing and measuring the quality of care. We draw on research conducted in a variety of low- and middle-income countries and identify areas of inherent complexity that require deeper research. In doing so, we reflect on what is meant by quality of care and on how perceptions and understanding of the quality of care influence health systems and affect the measurement of quality.
We have identified and structured our discussion around six conceptual and measurement challenges. First, it is recognized that, while they may not reflect actual quality, perceptions about the quality of care are an important factor in the utilization of care. Second, a patient's quality experience must be conceptualized as something that happens over time. Third, responsiveness to the patient is a key quality attribute.
Fourthly, the so-called rising factors, p. ex. Management at facilities and at higher levels is likely to be important for quality. Fifthly, quality can be considered as a social construction co-produced by different actors.
Finally, there are significant measurement challenges that require the adaptation and improvement of current approaches. The clinical quality of care refers to the interaction between healthcare providers and patients and to the ways in which health system inputs are transformed into health outcomes. The care provided must be effective, evidence-based and not under-used or overused. 7 The concept of clinical efficacy tends to divert attention away from supplies such as medications and equipment and focus on the care process, 6,8 While relatively easy to measure, the availability of supplies generally cannot be used in isolation to determine if the patient's health is likely to improve as a result of the care received, 9 Clinical processes are directly attributable to the behavior of healthcare providers and their measurement can provide a critical starting point in the development of methods to improve the care that patients receive. While health outcomes can be informative, they are likely to be just a crude measure of quality because of the unpredictability inherent in patient responses to health care.
9 Evaluating the clinical quality of care poses several conceptual and practical challenges. It requires a strong evidence base that can serve as a reference point for evaluating interventions. In high-income countries, treatments received can be compared with treatments recommended in national guidelines. However, in many low- and middle-income countries, these guidelines are not available or poorly enforced.
Even when such guidelines exist, evaluating what constitutes excessive caregiving is unclear and requires careful judgment. While harmful care must be distinguished from unnecessary care, such categorization can be difficult in practice. A large team of health professionals can provide care to a single patient through numerous interactions. In such circumstances, the measurement of the quality of care often focuses on a small number of different interventions with proven effectiveness.
There are several well-known practical challenges in assessing the clinical quality of care. For example, it may not be possible to observe interactions between patients and their doctors and, when possible, such observations may generate biases through the Hawthorne effect, that is,. Health care providers change their behavior when they are observed. 10 In low- and middle-income countries, medical records are often poorly maintained and may not reflect actual practice.
The use of so-called covert or standardized patients in the evaluation of clinical care can pose ethical problems,11 is generally limited to non-invasive conditions12 and is not a practical solution for routine quality measurement. 9 Despite these challenges, influential literature on the clinical quality of care is emerging in low- and middle-income countries, 2,13 Attempts to improve the quality of care have often been based on a biomedical understanding of quality, that is,. The conceptualization of a reference quality standard, guided by clinical guidelines, that may lead to a limited approach. Provider practices tend to vary despite the existence of liability procedures and guidelines.
14. Interventions may not be implemented as intended or may not be easily adapted to established models of care. 15. Clinical quality is important for patient outcomes, but perceptions of qualityof care , which do not correlate with actual quality , are likely to be the main drivers of utilization. 16 , 17 Patients may also have difficulty evaluating the qualityof care because they lack the medical experience and training of their doctor , 18 , 17 9 In South Africa , a key factor It was found that the factor that motivates patients to travel to access health services , including travel across borders , is patients ' perceptions of the qualityof health services. 20 Patients may...