1.
Measuring Quality of Care in Tanzania
Peter Binyaruka
Nov, 2015

2.
Introduction
Definition of quality of care (QoC)
According to Donabedian framework, there are 3 domains:
Donabedian, A. (1988)
Domain Content
Structure Facility environment, equipment, drugs, staffs, etc
Process Actions during healthcare
• Technical –content of care
• Experience of care –interpersonal, satisfaction
Outcome Changes in health status

3.
Qns. on structural factors
• What are the relevant factors?
• How to measure those factors?
• Binary, likert scale, etc
• Subgroups of attributes –eg. groups of related drugs
• On medical commodities –availability vs. stock-outs
• Which composite measure to use?
• Index –weighted vs. unweighted
• Factor score –via factor analysis, etc

4.
Structural factors considered in P4P -TZ
Factors that affect the context in which care is
delivered
1. Drugs
o Antimalarial drugs (6)
o Drugs during delivery care (3)
o ART drugs (8)
2. Vaccines (5)
3. Medical supplies (11)
4. Equipment (19)
5. Facility infrastructure
o Clean water availability
o Electricity availability
6. Staffing level

5.
Generating an index
• Using different items/ questions to create an index
• Composite score (index) solves the dimensionality problem with many
items
Index computation (unweighted)
o For each question as binary –[Yes=1/No=0] response
o For availability or stock-out
o Aggregated to get the total
Total=(∑responses)
o Divided the total by number of items to get the index
Index=[(∑responses)/n]

6.
Results (1): P4P effects on structural QoC
(TZ)Variables Baseline (%)
Intervention arm
Baseline (%)
Control arm
Difference Diff-in-diff, effect
All drugs (27 items) Stock out 54 46 8* -17***
Availability 39 44 -5* 13***
Delivery care drugs Stock out 56 39 17*** -29***
Availability 43 45 -2 15***
Antimalarials Stock out 42 40 2 -12**
Availability 60 69 -9** 20***
Vaccines (5) Stock out 17 13 4 -10*
Availability 95 93 2 5
ART drugs (8) Stock out 54 51 3 -7
Availability 42 32 9 -3
Equipment (19) Functioning 57 55 2 3
Availability 58 60 -2 2
Medical supplies
(11)
Stock out 39 26 13*** -15***
Availability 57 54 3 -3

7.
Results (2): P4P effects on structural QoC (TZ)
Variables Baseline (%)
Intervention
arm
Baseline (%)
Control arm
Differenc
e
Diff-in-diff,
effect
Staffing levels by cadre
Clinicians (number) 3.1 2.7 0.4 1.4
Nurses (number) 6.0 4.1 1.9 0.4
Paramedics (number) 4.7 4.4 0.3 1.8*
Total staff (number) 13.7 11.2 2.5 2.8
Facility infrastructure
Electricity (%) 69.0 70.1 -1.1 0.2**
Clean water (%) 73.3 79.5 -6.1 0.1

8.
Structure measures
“pros and cons”
Pros
• It can affect significantly the QoC provision
• Provides a key picture of providers’ capacity
• Often easy to observe and measure
• Measure of service delivery readiness
Cons
• Lack of specificity –i.e. Having a capacity and actual use
of that capacity
• Unclear link between structure and process/outcome
quality
✓ Often very complex and weak (Landon et al, 1998, 2001)
•

9.
Conclusions
▪ Structural aspect is one dimension in measuring QoC
▪ It has various pros and cons
▪ It is important –but other aspects should complement
▪ Need for evidence on the linkage (structure, process, outcome)
Method,
▪ Use of a composite score/ index solves the dimensionality problem
▪ But, various method for generating an index should be used
In Tanzania,
▪ P4P improved drug availability & lowering stock-outs
▪ Lowered vaccines & medical supplies stock-outs (but not availability)
▪ Improved electricity coverage
▪ But, no effect on ART, Equipment, and staffing level

10.
Thank you..!!

11.
References
• Donabedian, A. (1988). The quality of care. How can it
be assessed? JAMA, 260(12), 1743- 1748.
• Landon et al (1998). A conceptual model of the effects
of health care organizations on the quality of medical
care. JAMA, 279(17), 1377-1382.
• Landon et al (2001). Health plan characteristics and
consumers' assessments of quality. Health Affairs, 20(2),
274-286.