Performance Process measurement for improvement of PHC

Tittle: Performance of Primary Health Care in Tanzania : Shifting attention from ‘inputs-outputs’  measurement towards ‘processes-outcome’ measurements  in health care delivery.

Background

Many Health system in LMIC( like Tanzania) typically measure performance of primary health care using  data on inputs such as total number of health workers, medicines, and supplies available. They also measure performance using  outputs data like the percent of children vaccinated and the percent of pregnant women who deliver in  Primary health care facilities . These data  are crucial to measure  the performance of  primary health care , but they are not sufficient.

What most of the health systems  often lack is performance data about the important processes required to convert inputs to high-quality care delivery and coverage outputs critical to producing strong outcomes(WHO 2010, USAID 2012). There is little quality data on how often health workers are present and how  responsively they interact with  patients. There is even less information on the experience of patients regarding how their relationships with providers affect health care delivered to them.Addidtionally, there is paucity of evidence on how health workers acurately diagnose diseases.We will use Acute Respiratory Infection  s atracer disease among Children 0-2 years especially in these times of COVID-19 to measure PHC delivery effectiveness. These three aspects are important in  measuring performance of primary health care services -in terms of the processes that go into service delivery.

 Service delivery is  the interactions between a patient and their provider that influence whether a person gets the quality care they need -- the “black box” of primary health care.  Simply put, service delivery is not well understood and has not received enough attention. Countries and development partners need more and better information on this aspect of the primary health care system to understand what is standing in the way of people getting the care they need and drive the needed improvements.

Thus  the focus of this project is to    collect more and better data on service delivery processes particularly on the interactions between patients and their providers and assess how these interactions  influence whether  patients get the quality care they need, when they need. This is will involve assessment of availability of Health workers who are well trained, motivated and equitably distributed to effectively and efficiently provide Primary Health care services in a responsive and respectful way.  

Research Questions:

For Primary health care system to be effecive/efficient, it should be patient/people-centred, equitable, comprehensive and must ensure patients’ first contact to the health care system. The following are the projects' research questions which will guide its implementation.

•   What are existing barriers to achieving these attributes and what interventions can address them them?
• What is the average working hours of clinicians /nurses  per week?
• What is the extent of  health workers diagnosis accuracy (Using ARI as a tracer disease)
• What are patients perceptions of accessibility of clinicians/nurses out of working hours?
• How/in what ways do interactions between Health Care Workers at the primary Health Care facilities influence whether  patients get the quality care they need, when they need? (Human Resources for Health)

Objectives

Main Objective 

To conduct a Primary health care systems analysis in order to identify HRH  Capacities(I.e availability) and gaps  in terms of how they  affect the Primary health care performance  in delivering quality health services which are comprehensive, accessible, people-centered and stand as the  true reflection of patients’ first point of care.

Specific objectives

• To analyze the influence of interactions between health workers/providers and patients on the performance of primary health care delivery in terms of services provided being people centered,  accessible and a true reflection of the patients ‘first point of contact’ in the health system.
• To  assess HRH   Availability    in order to establish the capacity and gaps in  primary health facilities for offering comprehensive, people centered, accessible services  that  truly reflect patients’ first contact in the health system .
• To assess the process of diagnosis accuracy as a component of effective Primary health care.
• To determine average (%)working hours of clinicians and nurses in Primary health facilities
• To analyze patients perceptions of accessibility of clinicians and nurses out of working hours

Our solution aims at two interrelated objectives which ultimately intends  to improve measurement of Primary Health Care performance and thus strengthen delivery and monitoring of Primary Health Care services:

1) To improve measurement of processes leading  diagnostic Accuracy we will first collect baseline data  from selected  health facilities using treatment/management of Acute Respiratory Infections (ARI) (among children age 0 to 5 years)  as a tracer disease.We have selected this disease in this time of COVID-19  pandemic  because they share the same management processes. Researchers and Assistants will consult the Ministry of Health ARI treatment guidelines and will  collect data (in clinicians'/doctors' consultation rooms) and assess  the extent to which the guidelines and processes are accurately followed.

After collecting baseline data an intensive refresher training course (intervention) on adhering to ARI treatment/management process guidelines will be introduced to clinicians who manage ARI for a period of 14 days. Twenty(20) health facilities  will randomly be selected among which Ten (10) facilities will randomly be assigned with an intervention and Ten (10)  facilities will be control. These facilities will be followed for six month after which end-line data will be collected to analyze the intervention effect.

2) In order to improve measurement of processes that will make Primary health care to be more comprehensive, accessible, people-centered, equitable and stand as the  true reflection of patients’ first point of care, we will first collect baseline data  on the following aspects:

• To  assess HRH   Availability    in order to establish the HRH capacity and
  gaps in  primary health facilities for them to offer comprehensive, people centered, accessible services  that  truly reflect patients’ first contact in the health system
• To determine average (%)working hours of clinicians and nurses in Primary health facilities
• To analyze patients perceptions of accessibility of clinicians and nurses out of working hours

After collection of baseline data  an intervention will be introduced that will cover the same health facilities selected in the intervention one(1) above and will target Health Facilities Governing Committees (HFGCs) to improve their capacity in 1)managing and monitoring Health care workers and ensure that absenteeism is reduced and that they are available all the time including out of working hours and thus improve access to services.2) improve the capacity of HFGCs to ensure that health services offered by health workers are comprehensive, of high quality, equitable  and truly  reflect  person-centeredness  and patients'  first point of care. End-line data  will be collected and analyzed to measure whether the identified process indicators have improved or not as a result of implementation of the intervention.

The target population meant for our solution is the patients who are the primary users of the health services provided  at primary health facilities. By improving measurement of performance of Primary health care services delivery and ultimately strengthening the delivery of health services (if the measurements shows a downward  trend in terms of performance), patients and communities will positively benefit from the services offered by Primary health care facilities. Secondly, health workers will be the next beneficiaries through training to improve their capacities in diagnosing Acute Respiratory Infections (ARI) and thus provide proper treatment to their patients  to ultimately improve population health. Finally, planners and policy makers will benefit as the evidence generated through the experimentation of this solution will help the to leverage and allocate resources more effectively and efficiently to  sustain the improved  performance of primary health care service delivery. 

Our team is multidisciplinary and collaborative. It consists  of researchers  and policy makers/planners at the national and sub-national level  in order incentivize the swift uptake of evince to policy and planning. We will also involve patients and community members in all stages of the research and solution experimentation. In this case the team is a constitution and a representative of the communities for which the solution is meant to serve. In order to know the needs of those (communities)  to whom the solution is meant to/for,  participatory consultations and appraisals  were done with representatives of the community members, health facility managers/health workers, and policy/program planners to ensure that what is designed is actually what is needed. This was done to ensure that the proposed solution is meaningfully guided by constructive inputs from the intended beneficiaries.

NIMR, is a well established legal Public Health Research Entity. We are applying for this challenge as we are passionate to improve measurements of performance of primary health care in Tanzania with a view to introduce improvement interventions. With such a noble objective in the background of our minds, we are lacking  financial  resources that are needed to design, test  implement and later on scale-up our solution to other resource limited primary health sere settings. We are positive that, if successful , The challenge can help us overcome the financial barrier that we are currently facing to achieve our objectives. A Grant of US$ 150,000 Will suffice our purpose.

Previously used performance measurements of primary health care delivery have largely focused on input-output indicators and little attention has been given to process indicators.  What most of the health systems  often lack is performance data about the important processes required to convert inputs to high-quality care delivery and coverage outputs critical to producing strong outcomes. There is little quality data on how often health workers are present and how accurately they diagnose and treat patients. There is even less information on the experience of patients regarding how their relationships with providers affect health care delivered to them. These two  indicators are important in  measuring performance of primary health care services -in terms of the processes That go into service delivery and indeed te innovation brought about by this project.

The impact goal for the next year are as follows:

1) Improved measurement of Processes leading to strengthened primary health care performance

The impact goals for next 5 years include

1) Improved diagnostic accuracy and thus proper treatment of ARI

2) Reduced absenteeism of health workers and thus increased access to, and person centredness of  health services

Impact will be measured by looking at

1) %  reduction of absenteeism  compared to baseline

2) Increased adherence to guidelines which map the diagnosis and treatment processes

3) Improved (positive)perceptions of patients towards  the quality, timeliness and equity of the primary health care services provided

1)By empowering HFFCs, we expect that the capacity of health facility governing committees will be strengthened  to monitor the availability of health workers at the facility levels in order to ensure that services are accessible/available  during working hours and  and beyond working hours

2) By  improving  diagnostic accuracy through refresher training of clinicians, errors in diagnosis will be reduced and treatment will be improved and thus better health outcomes will be achieved

This project will generate evidence on the importance focusing of processes when measuring performance of primary health care service delivery.

Health Workers (in collaboration with research team members and patients representatives ) will be the primary data collectors. Data will be collected through interviews and record reviews. The main incentive to collect these data is to gain insights on the importance of processes that go into PHC service delivery in order to ultimately improve performance measurements and recommend on ways on how to improve  these processes towards improved delivery of primary health care services.

Making sure health systems researches  are diverse and representative of the populations they are studying is not just the right thing to do to promote inclusivity and equity; it is also just good science/ scientific practice. But despite growing efforts to improve, many researchers still fall short when it comes to reaching, recruiting and retaining diverse patient populations to participate in researches.

The absence of diversity in research projects has a significant impact on minority populations and possibly even the result of these research projects themselves, as health authorities move towards regulating and requiring a study population to be inclusive/diverse, contributing towards social and health disparities experienced by underrepresented, under-served, and minority populations. To ensure that diversity, equity, and inclusivity  are integrated into this  work, the following will be done:

1) Participants will be given the flexibility and convenience to use their own preferred language  during discussion

2) The research team and collaborative stakeholders will insure that  socioeconomic and demographic data are collected in a standardized way

3)The  research team  and collaborators will ensure that barriers to participation in the project are identified, analyzed and addressed in order to reduce (significantly)  the number of potential participants who might be hindered to participate

4) The project will collect and analyze data on social socio-cultural determinants of health  that may affect/hinder participants into their participation in the study, and address them accordingly.

We will use a 'Social partisanship business model'  in creating  value, delivering  value to  our expected beneficiaries (policy makers and planners, health workers and community members/ patients )  and ensure that we (researchers)  increasingly take a back seat and leave the improved Primary health care delivery processes do to the population. In this we believe that what counts is the benefit offered to the end users of Primary health care services

By Engaging the planners& policy makers right from the design through implementation of the solution to scale up, this solution will be sustainable as interest of key players will be harnessed well beforehand.

We have experience receiving Grants from the following funders
1) EU- 120, 000 Euros to implement a project that was meant to reduce maternal and child health inequalities in Tanzania, as part of a big multi-country study

2) PEPFAR/CDC- 155,000 US $ -To implement a study of the situation of Human Resources for Health in Tanzania