Increasing compliance with maternal and child care quality standards in Ecuador. Antimicrobial stewardship across 47 South African hospitals: an implementation study. Improving adherence to family planning guidelines in Kenya: an experiment. Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India Eliciting public preference for health-care resource allocation in South Korea. Citizen Participation in Patient Prioritization Policy Decisions: An Empirical and Experimental Study on Patients' Characteristics Involvement of patients or their representatives in quality management functions in EU hospitals: implementation and impact on patient-centred care strategies Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention Antibiotic Self-stewardship: Trainee-Led Structured Antibiotic Time-outs to Improve Antimicrobial Use Improving access to services and interactions with clients in Guatemala: the value of distance learning An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Improving private drug sellers' practices for managing common health problems in Nepal. The Critical Role of Supervision in Retaining Staff in Obstetric Services: A Three Country Study The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. Healthy public policy A conceptual cognitive framework. Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan. Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector.
OBJECTIVE To determine the effects of  hospital quality assurance interventions  on compliance with clinical st and ards , availability of essential drugs , client satisfaction , and utilization . DESIGN Quasi-experimental , prospect i ve study with four intervention hospitals and four control hospitals . All eight facilities were purposively selected and of comparable complexity . SETTING Ministry of Health secondary care facilities in Ecuador . INTERVENTIONS Facility-based quality improvement teams , job clarification , st and ards communication , refresher training , strengthening hospital pharmacy committees , monthly monitoring of compliance indicators , and formation of users ' committees . MEASURES Compliance with input and process st and ards , utilization of services , and patient satisfaction were measured monthly in both groups through review of clinical and administrative records , exit interviews , and patient satisfaction surveys . RESULTS After 12 months , the quality assurance interventions produced rapid increases in compliance with clinical st and ards in the intervention hospitals as compared with the control group . These improvements appeared as early as 2 months after the onset of the interventions . No differences were found between intervention and control groups in terms of trends in utilization patterns or client satisfaction . CONCLUSION Quality assurance interventions made a difference in technical quality of care . Patient satisfaction and utilization do not appear to be directly associated with short-term improvements in compliance with clinical st and ards . Quality improvement interventions may require longer periods and a specific aim at clients ' needs to demonstrate effects on utilization and satisfaction outcome variables BACKGROUND The available data on antimicrobial stewardship programmes in Africa are scarce . The aims of this study were to assess the implementation of an antimicrobial stewardship programme in a setting with limited infectious disease re sources . METHODS We implemented a pharmacist-driven , prospect i ve audit and feedback strategy for antimicrobial stewardship on the basis of a range of improvement science and behavioural principles across a diverse group of urban and rural private hospitals in South Africa . The study had a pre-implementation phase , during which a survey of baseline stewardship activities was done . Thereafter , a stepwise implementation phase was initiated directed towards auditing process measures to reduce consumption of antibiotics  ( prolonged duration , multiple antibiotics , and redundant antibiotic coverage ) , followed by a post-implementation phase once the model was embedded in each hospital . The effect on consumption was assessed with the WHO index of defined daily doses per 100 patient-days , and the primary outcome ( change in antibiotic consumption between phases ) was assessed with a linear mixed-effects regression model . FINDINGS We implemented and assessed the antimicrobial stewardship programme between Oct 1 , 2009 , and Sept 30 , 2014 . 116 662 patients receiving antibiotics at 47 hospitals during 104 weeks of st and ardised measurement and feedback , were review ed , with 7934 interventions by pharmacists recorded for the five targeted measures , suggesting that almost one in 15 prescriptions required intervention . 3116 ( 39 % ) of 7934 pharmacist interventions were of an excessive duration . The antimicrobial stewardship programme led to a reduction in mean antibiotic defined daily doses per 100 patient-days from 101·38 ( 95 % CI 93·05 - 109·72 ) in the pre-implementation phase to 83·04 ( 74·87 - 91·22 ) in the post-implementation phase ( p<0·0001 ) . INTERPRETATION Health-care facilities with limited infectious diseases expertise can achieve substantial returns through pharmacist-led antimicrobial stewardship programmes and by focusing on basic interventions . FUNDING None QUALITY PROBLEM Research in Kenya in the mid-1990s suggested poor quality family planning services and limited access to services . Clinical guidelines for family planning and reproductive health were published in 1991 and up date d in 1997 , but never widely distributed . CHOICE OF SOLUTION Managers and trainers chose intensive , district-level training workshops to disseminate guidelines and up date health workers on guideline content and best practice s. INTERVENTION Training workshops were held in 41 districts in 1999 . Trainees were instructed to up date their untrained co-workers afterwards . As a reinforcement , providers in r and omly selected areas received a ' cascade training package ' of instructional material s and training tips . Providers in 15 r and omly selected clinics also received ' supportive supervision ' visits as a second reinforcement . EVALUATION METHODOLOGY A cluster-r and omized experiment in 72 clinics assessed the overall impact of the training and the marginal benefits of the two reinforcing activities . Research ers and trainers created several dozen indicators of provider knowledge , attitudes , beliefs and practice s. Binomial and multivariate analyses were used to compare changes over time in indicators and in aggregated summary scores . Data from patient interviews were analysed to corroborate provider practice self-reports . Cost data were collected for an economic evaluation . RESULTS Post-test data collected in 2000 showed that quality of care and access increased after the intervention . The cascade training package showed less impact than supportive supervision , but the former was more cost-effective . LESSONS LEARNED Service delivery guidelines , when properly disseminated , can improve family planning practice s in sub-Saharan Africa Background After the launch of Janani Suraksha Yojana , a conditional cash transfer scheme in India , the proportion of women giving birth in institutions has rapidly increased . However , there are important gaps in quality of childbirth services during institutional deliveries . The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan . This intervention titled “ Parijaat ” was design ed by Action Research & Training for Health , in partnership with the state government and United Nations Population Fund . Methods The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan , India . These included district hospitals ( 9 ) , community health centres ( 32 ) and primary health centres ( 3 ) . The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment , feedback , training and action . The adherence to evidence based practice s before , during and after this intervention were measured using structured checklists and scoring sheets . Main outcome measures included changes in practice s during labour , delivery or immediate postpartum period . Results Use of several unnecessary or harmful practice s reduced significantly . Most importantly , proportion of facilities using routine augmentation of labour reduced ( p = 0 ) , episiotomy for primigravidas ( p = 0.0003 ) , fundal pressure ( p = 0.0003 ) , and routine suction of newborns ( 0 = 0.0005 ) . Among the beneficial practice s , use of oxytocin after delivery increased ( p = 0.0001 ) and the practice of listening foetal heart sounds during labour ( p = 0.0001 ) . Some practice s did not show any improvements , such as dorsal position for delivery , use of partograph , and h and -washing . Conclusions An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practice s at health facilities OBJECTIVES To identify the principles the public considers important and the trade-offs between different values in health-care re source allocation practice s. METHODS This study approached the issue in both qualitative and quantitative ways . In a qualitative study , two focus groups discussed the issues of re source allocation in health care . To facilitate the discussion , a simple ranking task and a series of pairwise choice practice s were implemented . A discrete choice experiment survey question naire was also administered to a sample of the general population . Attributes and levels were determined through literature review s and the results from the focus group interview . We used a r and om-effect probit model to assess the effects of each attribute . RESULTS Through the focus group interviews , we found strong public support for the principle of equal opportunity . The participants thought that the severity of disease was the most important criterion when setting priorities . The majority supported the idea that the most disadvantaged should have the highest priority even when their health gains are less than those of others . The discrete choice experiment results showed that the severity of disease , health gains , and patients ' socioeconomic status significantly influence their choices , with each parameter having an expected sign . CONCLUSION The results showed that Koreans support not only health maximization but also equal opportunity , fair re source allocation , and e quality Health systems worldwide are grappling with the need to control costs to maintain system viability . With the combination of worsening economic conditions , an aging population and reductions in tax revenues , the pressures to make structural changes are expected to continue growing . Common cost control mechanisms , e.g. curtailment of patient access and treatment prioritization , are likely to be adversely viewed by citizens . It seems therefore wise to include them in the decision making processes that lead up to policy changes . In the context of a multilevel iterative mixed- method design a quantitative survey representative of the German population ( N = 2031 ) was conducted to probe the acceptance of priority setting in medicine and to explore the practicability of direct public involvement . Here we focus on preferences for patients ' characteristics ( medical aspects , lifestyle and socio-economic status ) as possible criteria for prioritizing medical services . A question naire with closed response options was fielded to gain insight into attitudes toward broad prioritization criteria of patient groups . Furthermore , a discrete choice experiment was used as a rigorous approach to investigate citizens ' preferences toward specific criteria level in context of other criteria . Both the question naire and the discrete choice experiment were performed with the same sample . The citizens ' own health and social situation are included as explanatory variables . Data were evaluated using corresponding analysis , contingency analysis , logistic regression and a multinomial exploded logit model . The results show that some medical criteria are highly accepted for prioritizing patients whereas socio-economic criteria are rejected Objective The objective of this study was to describe the involvement of patients or their representatives in quality management ( QM ) functions  and to assess associations between levels of involvement and the implementation of patient-centred care strategies . Design A cross-sectional , multilevel study design that surveyed quality managers and department heads and data from an organizational audit . Setting R and omly selected hospitals ( n = 74 ) from seven European countries ( The Czech Republic , France , Germany , Pol and , Portugal , Spain and Turkey ) . Participants Hospital quality managers ( n = 74 ) and heads of clinical departments ( n = 262 ) in charge of four patient pathways ( acute myocardial infa rct ion , stroke , hip fracture and deliveries ) participated in the data collection between May 2011 and February 2012 . Main Outcome Measures Four items reflecting essential patient-centred care strategies based on an on-site hospital visit : ( 1 )  formal survey seeking views of patients and carers , ( 2 ) written policies on patients ' rights , ( 3 ) patient information literature including guidelines and ( 4  ) fact sheets for post-discharge care .  The main predictors were patient involvement in QM  at the ( i ) hospital level and ( ii ) pathway level . Results Current levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level ( mean score 1.6 on a scale of 0 to 5 , SD 0.7 ) , but even lower at departmental level ( mean 0.6 , SD 0.7 ) . We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies ; however , the smallest hospitals were more likely to have implemented patient-centred care strategies . Conclusions There is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care ; however , lack of evidence should not be interpreted as evidence of no effect Background Dem and -side financing projects are now being implemented in many developing countries , yet evidence showing that they reach the poor is scanty . Methods A  maternal health voucher scheme provided voucher-paid services in Jhang , a predominantly rural district of Pakistan , during 2010 . A pre-test/post-test quasi-experimental design was used to assess the changes in the proportion of facility-based deliveries and related maternal health services among the poor . Household interviews were conducted with r and omly selected women in the intervention and control union councils , before and after the intervention . A strong outreach model was used . Voucher promoters were given basic training in identification of poor women using the Poverty Scorecard for Pakistan , in the types of problems women could face during delivery , and in the promotion of antenatal care ( ANC ) , institutional delivery and postnatal care ( PNC ) . Voucher booklets valued at Rs . 4,000 ( $ 48 ) , including three ANC visits , a PNC visit , an institutional delivery , and a postnatal family planning visit , were sold for Rs . 100 ( $ 1.2 ) to low-income women targeted by project outreach workers . Women suffering from complications were referred to emergency obstetric care services . Analysis was conducted at the bivariate and the multivariate levels . At the multivariate level , logistic regression analysis was conducted to determine whether the increase in institutional delivery was greater among poor women ( defined for this study as women in the fourth or fifth quintiles ) relative to non-poor women ( defined for this study as women in the first quintile ) in the intervention union councils compared to the control union councils . Results Bivariate analysis showed significant increases in the institutional delivery rate among women in the fourth or fifth wealth quintiles in the intervention union councils but no significant changes in this indicator among women in the same wealth quintiles in the control union councils . Multivariate analysis showed that the increase in institutional delivery among poor women relative to non-poor women was significantly greater in the intervention compared to the control union councils . Conclusions Dem and -side financing projects using vouchers can be an effective way of reducing inequities in institutional delivery Antibiotic resistance is a major public health issue that substantially affects patient outcomes and costs ( 1 ) . With new antimicrobials few in number and far off in development ( 2 ) , we need to maximize the effectiveness of today 's therapy and preserve it for tomorrow by preventing resistance . This and the prevention of Clostridium difficile infection are 2 of the main goals of antimicrobial stewardship . There are several methods of stewardship ( 3 ) ; one of the most effective , prospect i ve audit and feedback , uses consultants in infectious diseases or trained pharmacists to review use case by case ( 4 ) . The expertise required limits the implementation of such programs ( 3 , 4 ) . Given that the Centers for Disease Control and Prevention ( CDC ) suggests that nearly 50 % of antimicrobial use is unnecessary or inappropriate ( 5 ) , it is clear that widely available methods of stewardship need to be developed . In an online campaign called Get Smart for Healthcare , the CDC suggests that clinicians take an antimicrobial time-out to review the dose , duration , and indication when cultures and new clinical information become available ( 6 ) . While planning our local stewardship program , we recognized that our re sources were limited and our needs great . Although it seemed logical that time-outs could lead to reduced antibiotic use , we believed that without education and a formal structure , they would be forgotten or underutilized . We developed an educational curriculum and electronic checklist to provide structure and subsequently implemented m and atory time-out audits on our internal medicine clinical teaching units . These time-out audits were integrated into routine clinical practice by our senior residents , who performed a process that we called antimicrobial self-stewardship . Methods Setting The study was conducted in two 23-bed internal medicine clinical teaching units in the Montreal General Hospital , a 417-bed tertiary care hospital . Each unit has an attending physician , a senior resident ( second-year ) , 2 first-year residents , and 2 medical students . A third-year resident is shared between the teams who focuses their time on quality improvement projects , teaching , and procedural support . Attending physicians work a variable number of 2-week blocks per year . Resident physicians have three to four 1-month rotations per year . Interventions The study investigators included consultants in infectious diseases , critical care medicine , and general internal medicine with expertise in the management of hospitalized patients . Through consensus , we developed a 30-minute teaching session ( Data Supplements 1 and 2 ) that addressed the importance of antibiotic stewardship , our guidelines for the most common infectious diseases encountered , and how to perform self-stewardship . These sessions were given monthly to all rotating housestaff . Data Supplement 1 . Antimicrobial Self-Stewardship : Putting the CDCs antibiotic timeouts to work Data Supplement 2 . Antimicrobial Self-Stewardship : How to use the online tool Our stewardship team ( Drs . Lee and Frenette ) developed an online checklist ( Data Supplement 3 ) that formalized each time-out audit into a step-by-step process meant to approximate how an infectious diseases specialist might approach prospect i ve audit and feedback . We specifically targeted 4 key antimicrobials : 1 ) carbapenems , which were the most expensive class with the broadest spectrum of activity ; 2 ) moxifloxacin , which was chosen to reduce C. difficile infection and to reduce gram-negative exposure to the quinolones ; 3 ) piperacillintazobactam , which is the most widely used broad-spectrum antibiotic at our institution ; and 4 ) vancomycin , because it is potentially overused in patients without risk factors for infection with -lactamresistant gram-positive organisms and is associated with nephrotoxicity . Data Supplement 3 . Stewardship checklist To limit workload , we chose to implement audits twice weekly . On each audit day , the senior resident would apply the checklist to all patients receiving antibiotics . Each unit audited required 30 minutes to complete . Residents were reminded to perform the audits by the unit pharmacists , but performance was not directly observed . At the end of each month , antibiotic use was review ed using the qualitative data from the audits and the results were fed back . Measurements Information on antibiotic use from 1 April 2010 to mid-January 2012 ( control period ) and from mid-January 2012 until the beginning of June 2013 ( intervention period ) was obtained from the pharmacy as World Health Organization defined daily doses ( DDDs ) ( 7 ) . The DDDs were available by fiscal period ( 13 periods per year , beginning in April ) and were st and ardized per 1000 patient-days . Cost was st and ardized to the June 2013 price per DDD in Canadian dollars . Because an automatic substitution from ticarcillinclavulanate to piperacillintazobactam occurred in mid-2011 , the lower price was used for both . Only antibacterial agents were included . Rates of nosocomial C. difficile infection were calculated as the number of polymerase chain reactionpositive cases per 10000 patient-days . In keeping with Quebec reporting st and ards , a nosocomial case was identified when symptoms occurred more than 3 days after admission or symptoms caused readmission in a patient who had been hospitalized on our unit within the previous 2 months and who was not a resident in a long-term care facility . Primary outcomes were the cost and quantity of antibiotics  used both overall and with a focus on our targeted drugs , and rates of C. difficile infection per 10000 patient-days . Secondary outcomes were length of stay , number of monthly intensive care unit ( ICU ) transfers , and mortality per 10000 patient-days . McGill University Health Center ethics approval was obtained . Statistical Analysis We conducted segmented regression analysis of an interrupted time series , as described by Wagner and colleagues ( 8) . Models were created for total antibiotic use and for each of the 4 targeted drugs or classes . Each interrupted time series can be specified as E(Y ) = constant + 0*t + 1*X1 + 2 * t*X1 , where Yt is the dependent variable ( antibiotic use ) , t indicates the order of the observations ( fiscal period ) , and X1 is a dummy variable indicating whether the observation was taken before or after the intervention . In this method , we use the preintervention period as the control for the postintervention period . If 1 differs statistically from zero , this implies that there was a change in the absolute level of use of the drug after intervention . If 2 differs statistically from zero , this implies that there was a change in the trend of use ( slope of the line ) after intervention . The time-series analyses were done using the tsset and regress comm and s. Autocorrelation in the residuals was evaluated by using the DurbinWatson method ( estat dwatson comm and ) . Rates of C. difficile infection and mortality before and after intervention were compared by using the Z test for incidence rate ratios . Before- and -after comparisons in the average length of stay and the median monthly number of ICU transfers were compared by using the 2-tailed t test and Wilcoxon rank-sum test , respectively . All comparisons were performed by using Stata , version 11 ( StataCorp ) . Role of the Funding Source This project was completed without any funding . Faculty members donated their time . Resident physicians were paid their usual salary because the time-out audits were considered clinical work . The monthly faculty time required was 1 hour , and the monthly resident time totaled 8 hours ( 108 hours per year ) . Results During the intervention period ( mid-January 2012 to the start of June 2013 ) , 23 staff physicians attended a median of 6 weeks each . There were 15 senior residents who worked a median of 12 weeks each . There were a total of 1548 admissions , with 1513 time-out audits performed on 1062 unique infections involving 679 unique patients . Auditing was performed on 80 % of assigned days . Pneumonia was the most common infection ( 25 % ) , followed by urinary tract infection ( 12 % ) , C. difficile ( 9 % ) , and cellulitis ( 7 % ) . The top 5 classes of antibiotics used at the time of initial time-out audit were antipseudomonal penicillins ( 23 % ) , fluoroquinolones ( 16 % ) , glycopeptides ( 13 % ) , narrow-spectrum -lactams ( 12 % ) , and third-generation cephalosporins ( 7 % ) . The initial time-out led to a change in antibiotic therapy in 15 % ( 154 ) of infections audited . Among these changes , 55 % involved dose or duration only and the other 45 % involved a change in therapy . Changes were less frequent in subsequent audits ( 9 % ) . These data are presented in Table 1 . Changes were more common in patients receiving piperacillintazobactam ( 20 % ) , a fluoroquinolone ( 20 % ) , or vancomycin ( 14 % ) than in those receiving a carbapenem ( 6 % ) ( Table 2 ) . Changes or cessations that occurred before or between the time-outs were not captured . Table 1 . Antibiotic Changes Made During the First and Subsequent Audits Table 2 . Antibiotic Changes Made During the First Audit , by Initial Antibiotic Choice The total annual st and ardized cost of antibiotics for the units decreased from $ 149743 ( January 2011 to December 2011 ) to $ 80319 ( January 2012 to December 2012 ) , for a year-on-year savings of $ 69424 ( 46 % reduction ) . Of the savings , $ 54150 ( 78 % ) was related to carbapenem use and $ 15274 ( 22 % ) was due to other classes . On the basis of 108 physician-hours per year , this would represent a return of $ 140 to $ 640 per hour , excluding and including carbapenems , respectively . In the time-series analysis , the total monthly use of antibiotics was unchanged ( P= 0.91 for level ; P= 0.100 for trend ) and averaged 720 DDDs per 1000 patient-days per period throughout the study ( Figure 1 ) . Figure 2 shows the monthly use per fiscal period in DDDs per 1000 patient-days for moxifloxacin , carbapenems , vancomycin , and antipseudomonal penicillins . The only reliable , statistically significant change was a reduction Objective To develop and test a distance-learning programme to improve the quality and efficiency of family planning services in Guatemala . Methods The setting was rural family planning services in Guatemala . The study design was quasi-experimental with one intervention and one control group and with pre- and post-intervention measures . Two staff members from each of 20 r and omly selected health districts were trained as leaders of the training programme . In turn , the 40 trainers trained a total of 240 service providers , under the supervision of four health area facilitators . The results were compared with 20 r and omly selected control health districts . The intervention was a distance-learning programme including 40 in-class hours followed by 120 inservice practice hours spread over a 4-month period . Distinctively , the programme used a cascade approach to training , intensive supervision , and close monitoring and evaluation . Patient flow analysis was used to determine number of contacts , waiting times , and the interaction time between service providers and clients . Consultation observations were used to assess the quality and completeness of reproductive health information and services received by clients . Results The intervention showed a positive impact on reducing the number of contacts before the consultation and client waiting times . More complete services and better quality services were provided at intervention clinics . Some , but not all , of the study objectives were attained . The long-term impact of the intervention is as yet unknown . Conclusion Distance-learning programmes are an effective methodology for training health professionals in rural areas Maternal health services continue to favour the wealthiest in lower and middle income countries . Debate about the potential of performance-based financing ( PBF ) to address these disparities continues . As PBF is adopted by countries , it is critical to underst and the equity effects for maternal services . The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population . In Rw and a , PBF was design ed to increase health service use , which was universally low . Paired districts were r and omly assigned to intervention and control for PBF implementation . Using Rw and a 's Demographic Health Survey data from 2005 ( pre-intervention ) and 2007 - 8 ( post-intervention ) , a cluster-level panel data set of 7899 women 15 - 49 years of age from intervention ( 4477 ) and control districts ( 3422 ) was created . The impact of PBF on reported use of facility deliveries , antenatal care ( ANC ) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects . Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women . The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts ( P = 0.014 ) , while no significant effects were noted for ANC visits or modern contraceptive use . Service use increased for intervention and control population s and across all wealth quintiles from 2005 to 2007 , with no evidence that PBF was a pro-poor or a pro-rich strategy . Insurance remained a positive predictor of service use . This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services , such as facility deliveries , may improve service use overall . However , if the equity gap is extreme , then a PBF programme without equity targets will do little to alleviate disparities BACKGROUND In most Asian countries , 50 - 90 % of pharmaceutical sales are made in private drug outlets , by personnel with some training in drugs but not for the treatment of common health problems . The objective of the study was to determine effects of focused training for private drug sellers to improve practice s in treating acute respiratory infections and diarrhoea in children , and anaemia in pregnancy in Nepal . METHODS R and omized controlled , four way nested design study incorporating four interventions for drug retailers in both hill and terai districts . One group received mailed printed educational material s followed by mailed feedback ; a second received small group training followed by feedback ; a third received small group training only ; and a fourth , the control group , received no intervention . Surrogate customer method was used to assess practice s. Outcomes were measured using multivariate linear regression . RESULTS A significant increase in the asking of key history questions , recommendation ( prescribing by drug retailers ) of cotrimoxazole , and advice-giving for pneumonia ; a significant increase in ORS recommendation , and advice giving for diarrhoea including the avoidance of antidiarrhoeals ; and a significant increase in asking key history questions and recommending appropriate products in pregnancy cases . CONCLUSIONS Training intervention as well as training followed by practice feedback was effective in improving the management of common illnesses and pregnancy by private drug sellers Millennium Development Goal ( MDG ) 5 commits us to reducing maternal mortality rates by three quarters and MDG 4 commits us to reducing child mortality by two-thirds between 1990 and 2015 . In order to reach these goals , greater access to basic emergency obstetric care ( EmOC ) as well as comprehensive EmOC which includes safe Caesarean section , is needed .. The limited capacity of health systems to meet dem and for obstetric services has led several countries to utilize mid-level cadres as a substitute to more extensively trained and more internationally mobile healthcare workers . Although this does provide greater capacity for service delivery , concern about the performance and motivation of these workers is emerging . We propose that poor leadership characterized by inadequate and unstructured supervision underlies much of the dissatisfaction and turnover that has been shown to exist amongst these mid-level healthcare workers and indeed health workers more generally . To investigate this , we conducted a large-scale survey of 1,561 mid-level cadre healthcare workers ( health workers trained for shorter periods to perform specific tasks e.g. clinical officers ) delivering obstetric care in Malawi , Tanzania , and Mozambique . Participants indicated the primary supervision method used in their facility and we assessed their job satisfaction and intentions to leave their current workplace . In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave . We find no evidence that facility level factors modify the link between supervisory methods and key outcomes . We interpret this evidence as strongly supporting the need to strengthen leadership and implement a framework and mechanism for systematic supportive supervision . This will promote better job satisfaction and improve the retention and performance of obstetric care workers , something which has the potential to improve maternal and neonatal outcomes in the countdown to 2015 BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition . Patients visiting registry clinics accessed counseling programs statistically significantly more often ( P < 0.001 ) than patients receiving care in the control condition . Other endpoints did not statistically significantly differ between the experimental conditions . CONCLUSIONS The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practice s and patient behaviors was mixed . Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment More than three decades ago , the report A New Perspective on the Health of Canadians ( 1974 ) highlighted the significance of other determinants than the healthcare system . The adoption of healthy public policy was identified in the Ottawa Charter ( 1986 ) as one of five strategies aim ing to promote health . It must now be acknowledged that even if we have a better underst and ing of health determinants , the latter are not necessarily taken into consideration when developing public policies . The purpose of this paper is to help foster a better underst and ing of the healthy public policies by presenting a conceptual framework that is inspired by the Advocacy Coalition Framework developed by Sabatier and Jenkins-Smith ( 1999 ) . On the one h and , this paper intends to show the relevance of the notion of subsystem of public policies in healthy public policy process . On the other , it aims to convince that it is necessary to channel the analysis around the decision-making process , the prospect i ve evaluation of public policies and the knowledge transfer and appropriation process . Finally , the purpose of this paper is to contribute to the ongoing debate about the role of knowledge , values or beliefs in the formulation and adoption of public policies . After briefly summarizing the theoretical developments in studies on public policies , the logic and components of the ACF are introduced . The main criticisms regarding the ACF are then examined , followed by an introduction of the conceptual framework that is adapted to the reality of healthy public policies . The notions of the subsystem of public policy(ies ) , of process and of learning process are central to this framework BACKGROUND Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations ( NGOs ) , inequity in access persists between the poor and non-poor . This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan . METHOD Contracts to NGOs were made to deliver a common set of primary care services in each province , with the funding agencies determining contract terms . The contracting approaches could be classified into three contracting out types ( CO-1 , CO-2 and CO-3 ) and a contracting-in ( CI ) approach based on the contract terms , design and implementation . Exit interviews of patients attending r and omly sample d primary health facilities were collected through systematic sampling across 28 provinces at two time points . The outcome , the odds that a client attending a health facility is poor , was modelled using logistic regression with a robust variance estimator , and the effect of contracting was estimated using the difference-in-difference approach combined with stratified analyses . RESULTS The sample covered 5960 interviews from 306 health facilities in 2005 and 2008 . The adjusted odds of a poor client attending a health facility over time increased significantly for facilities under CO-1 and CO-2 , with odds ratio of 2.82 ( 1.49 , 5.36 ) P-value 0.001 and 2.00 ( 1.33 , 3.02 ) P-value 0.001 , respectively . The odds ratios for those under CO-3 and CI were not statistically significantly different over time . When compared with the non-contracting facilities , the adjusted ratio of odds ratios of poor status among clients was significantly higher for only those under CO-1 , ratio of 2.50 ( 1.32 , 4.74 ) P-value 0.005 . CONCLUSIONS CO-1 arrangement which allows contractors to decide on how funds are allocated within a fixed lump sum with non-negotiable deliverables , and actively managed through an independent government agency , is effective in improving equity of health services provision BACKGROUND Early detection and effective case management of tuberculosis ( TB ) among a high-risk group of material ly poor farm workers in an area of the Cape Winel and s , South Africa , presents special challenges to the health community , where re source constraints lead to service reduction . In order to address this problem , local nurses established a collaborative partnership between permanent farm workers and their families , their employers , selected non-governmental organizations and the public health sector . In consultation with stakeholders , they developed an intervention primarily focusing on having peer selected trained lay health workers ( LHWs ) on farms , mentored and managed by nurses . PURPOSE To describe the complex process of implementation and evaluation of the LHW project , and provide a summary of a number of discrete studies evaluating the effectiveness , cost implication s , and the perceptions and experiences of key stakeholders of the intervention . METHODS Quantitative and qualitative research methods conducted within the context of a pragmatic unblinded community cluster r and omized control trial were used . Emphasis was placed on an iterative participatory interaction between the research ers and key stakeholders . RESULTS The intervention contributed to significantly better successful treatment completion rates among adult new smear-positive TB cases . The process implemented proved cost-effective and was pivotal in initiating a community-based social development programme . CONCLUSIONS The use of peer-selected LHWs within a wider programme of integrated care design ed to merge technical biomedical approaches to disease management with more holistic social development activities , appears essential to meet the complex health needs in conjunction with public health of the rural poor
Authors ' conclusions Training probably improves quality of care ( i.e. adherence to recommended practice ) , regulation may improve quality of care , and we are uncertain about the effects of co‐ordination on quality of private for‐profit healthcare services in LMICs .
Background Governments use different approaches to ensure that private for‐profit healthcare services meet certain quality st and ards .
Such government guidance , referred to as public stewardship , encompasses government policies , regulatory mechanisms , and implementation strategies for ensuring accountability in the delivery of services .
However , the effectiveness of these strategies in low‐ and middle‐income countries ( LMICs ) have not been the subject of a systematic review .
Objectives To assess the effects of public sector regulation , training , or co‐ordination of the private for‐profit health sector in low‐ and middle‐income countries .