Improving primary health care needs improved measurement Margaret E. Kruk, MD, MPH Associate Professor of Global Health Harvard T.H. Chan School of Public Health

Two challenges Not using the data we have Don’t have key data we need 1

Outline Describing primary care: what, where, who? Measuring the value of primary care: quality, equity, and effective coverage Measurement gaps and future research 2

Service Provision Assessment surveys 3 Primary care facility = non-hospital

Censuses even! 4 Primary care facility = non-hospital Health system census

Describing primary care: what, who, where? 5

What is a primary care facility? 6

Who manages primary care? 7

Who provides primary care? 8

What traditional services do primary care facilities provide? 9

What new services do primary care facilities provide? 10

What services are available where? IMCI 11

12 What services are available where? NCDs

Measuring the value of primary care: quality, equity, effective coverage 13

14 Domains of primary care Affordable and timely Geographic Financial Timely First contact Effective Facility infrastructure Organization and management Provider effort Provider competence Provider motivation Safety People centered Patient experience Coordination Comprehensiveness Continuity

15 Affordable and timely Geographic: N/A Financial Primary care services without fees (5 items) Cost not a problem for clients Timely Clients wait less than an hour ANC, SC, FP services offered daily First contact Child did not visit other facility before coming to this facility SPA measures of primary care quality

16 Effective Facility infrastructure Structure (13 items) Equipment (17 items) Medication (21 items) Organization and management Routine management and community meetings Quality assurance, client feedback External supervision Provider effort Visit duration > 15 minutes Provider competence Facility includes MD Providers take child’s temperature in SC visit Provider motivation Providers receive salary supplement Providers have opportunity for promotion Providers have written job description Safety Appropriate waste disposal (4 items) Infection control items in primary care areas (4 items, 3 rooms) SPA measures of primary care quality

17 People centered Patient experience Clients very satisfied with care Caregivers know diagnosis of child FP providers discuss client’s method of interest ANC providers explain how to take iron pills Coordination Agreement for return of outsourced HIV tests Caregivers told where to go for referral of sick child Communication & transport available Comprehensiveness Maternal / child health services available (5 items) Infectious disease services available (3 items) Continuity Facility maintains client records for primary care Caregivers will bring child back to facility if s/he doesn’t improve SPA measures of primary care quality

What is the quality of primary care? PQoC Index 18

Primary care quality close up: five countries in East and Southern Africa 19

What is the quality of PC at subnational level? 20

Quality in the three primary care domains 21

Is primary care providing effective coverage of essential services? Moving beyond access: coverage does not automatically mean good care or better health Effective coverage = coverage * quality 22

Power of combining existing data 23 Service Provision Assessment: quality of IMCI care Ability to drink Vomiting Convulsion Cough Diarrhea Fever Weight Growth chart Palmar pallor Severe wasting Oedema of both feet Vaccination status Temperature Breastfeeding / other fluids (infants) Feeding changes during illness (infants) Demographic and Health Survey: use of child health service for sick child If your child had fever (cough), did you seek advice or treatment? ✚

What is the coverage of sick child care? 24

What is the effective coverage of sick child care? 25 Effective coverage = coverage * quality

What is the coverage of antenatal care? 26

What is the effective coverage of antenatal care? 27 Effective coverage = coverage * quality (40-item index of observed ANC quality)

Do poor people receive poor quality care? 28

Do poor people receive poor quality care? 29

What don’t we know? Undefined Primary care facility Minimum standard for quality in primary care Unmeasured Patient preferences, needs, experience Non-communicable disease, mental health care – provision or quality Unknown Which elements of primary care quality most critical for patient outcomes Which measurement approaches permit rapid, ongoing quality assessment 30

Provocations Put patients at the center of primary care improvement Assess actual not assumed primary care performance Get serious on measurement: brief, relevant, fast data Be guided by data not ideology 31

Acknowledgements Hannah Leslie, Harvard Anna Gage, Harvard Asaf Bitton, Ariadne Labs Lisa Hirschhorn, Ariadne Labs Jean Paul Joseph, Zanmi Lasante, Haiti Humphreys Nsona, Ministry of Health, Malawi Godfrey Mbaruku, Ifakara Health Institute, Tanzania 32