This presentation was given at the pay-for-performance workshop in Tanzania, November 2015.

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.