Understanding and enhancing approaches to quality improvement in small and medium sized private facilities in sub-Saharan Africa

在低收入和中等收入国家，私营部门是治疗的主要和日益增长的来源，但人们对护理的安全性和质量有相当大的担忧。近年来，中小型私人诊所增长迅速，但它们的监管往往很差，人们对提高它们提供的护理质量的干预措施的有效性知之甚少。该项目旨在解决这一证据差距。这项研究是在国际非政府组织PharmAccess开发的一项创新干预措施的背景下进行的，该干预措施利用与国际认证机构共同制定的标准，将临床标准和逐步认证的好处扩展到LMIC的中小型设施。PharmAccess模式旨在提高设施提供的护理质量，并塑造更广泛的医疗保健和金融市场以及政策环境。该模型有几个组件。根据一套“SafeCare”结构质量标准对卫生设施进行评估，对质量改进和业务技能进行培训，并协助制定质量和业务改进计划。他们定期接受指导访问，还与医药准入医疗信贷基金联系在一起，这是一个社会投资基金，促进获得银行贷款，为计划的实施提供资金。其目的是创造一系列良性循环，SafeCare评估分数的改善标志着个人和机构购买者护理质量的提高，从而增加了对卫生服务的需求；改善了业务绩效，确保了进一步获得信贷和质量收益的可持续性。这项研究将首先分析PharmAccess到目前为止在坦桑尼亚和肯尼亚例行收集的二级数据，以检查SafeCare评估分数随时间的变化以及与这些变化相关的因素。然后，我们将进行一项随机对照试验，以前瞻性地评估将PharmAccess模式推广到坦桑尼亚更多的私人营利性和基于信仰的机构对护理质量的影响。该试验将通过对实施两年后的120个干预设施和120个对照设施的比较来评估干预对患者接受的护理质量的影响。这些数据还将被用来评估SafeCare评估分数(衡量基础设施、技术和标准操作程序等投入的可用性)与患者护理的技术和感知质量措施(涉及护理者和患者之间的互动)之间的关系。技术质量将通过标准化的患者(隐蔽的演员)和临床小插曲(公开的角色扮演)来衡量，感知的质量通过患者访谈来衡量。此外，将在坦桑尼亚的30个干预设施和8名执行工作人员中进行深入访谈，以评估参与PharmAccess模式的预期效益和成本，以及影响质量改进和业务业绩的因素。最后，将采访30名国家级关键信息者，以探索PharmAccess模式如何塑造医疗保健和医疗保健融资市场，以及坦桑尼亚和肯尼亚的政策环境。预计结果将对改善私营部门护理的证据基础和衡量患者护理过程质量的文献做出重要贡献。研究结果将对国家和国际政策制定者和方案管理者大有裨益，他们对更广泛地加强私营部门保健和保健系统感兴趣，并对保健系统内要求遵守质量标准的所有组织(例如，社会健康保险方案、社会特许经营方案、监管机构)具有重要影响。

The private sector is a major and growing source of treatment in low- and middle-income countries (LMIC), but there is considerable concern about the safety and quality of care. Recent years have seen fast growth in small and medium sized private clinics, but their regulation is often poor, and relatively little is known about the effectiveness of interventions to improve the quality of care they provide. This project aims to address this evidence gap. The research takes place in the context of an innovative intervention developed by the international NGO PharmAccess that extends the benefits of clinical standards and stepwise certification to small and medium-sized facilities in LMIC, using standards developed with international accreditation bodies. The PharmAccess model seeks to improve the quality of care that facilities provide as well as to shape the broader healthcare and finance markets and policy environment. There are several components to the model. Health facilities are assessed on a set of "SafeCare" structural quality standards, trained on quality improvement and business skills, and assisted in the development of a quality and business improvement plan. They receive regular mentoring visits and are also connected with the PharmAccess Medical Credit Fund, a social investment fund which facilitates access to bank loans to finance implementation of the plan. The aim is to create a series of virtuous circles, with improvements in SafeCare assessment scores signalling improved quality of care to individual and institutional purchasers, thus increasing demand for health services; and improved business performance ensuring further access to credit, and the sustainability of quality gains.The research will begin with an analysis of secondary data collected routinely by PharmAccess in Tanzania and Kenya to date to examine changes in the SafeCare assessment scores over time and factors associated with these changes. We will then undertake a randomised controlled trial to evaluate prospectively the impact on quality of care of the roll out of the PharmAccess model to additional private for-profit and faith-based facilities in Tanzania. The trial will assess the effects of the intervention on the quality of care received by patients through comparison of 120 intervention and 120 control facilities after 2 years of implementation. These data will also be used to assess the relationship between SafeCare assessment scores (which measure availability of inputs such as infrastructure, technology and standard operating procedures) and measures of technical and perceived quality of patient care (which concern the interaction between caregivers and patients). Technical quality will be measured through standardised patients (covert actors) and clinical vignettes (overt role-playing), with perceived quality measured through patient interviews. In addition, in-depth interviews will be conducted in 30 intervention facilities and with 8 implementing staff in Tanzania to assess the perceived benefits and costs of participating in the PharmAccess model, and factors affecting quality improvement and business performance. Finally, 30 national level key informants will be interviewed to explore how the PharmAccess model shapes the market for healthcare and healthcare finance, and the policy environment in both Tanzania and Kenya.The results are expected to make an important contribution to the evidence base on improving private sector care and to the literature on measuring process quality of patient care. The findings will be of substantial benefit to national and international policy makers and programme managers who are interested in private sector healthcare and health systems strengthening more generally, with important implications for all organisations within the health system that require adherence to quality standards (eg, social health insurance programmes, social franchising programmes, regulatory agencies)