Health Policy and Planning Advance Access originally published online on November 23, 2005
Health Policy and Planning 2006 21(1):65-74; doi:10.1093/heapol/czj006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Original article |
The health service coverage of quality-certified primary health care units in Metro-Manila, the Philippines
Adviser, Local Health Systems Development, German Technical Cooperation (GTZ), Philippines
Correspondence: Amador R Catacutan, MD, 5 Real Street, Real Village No. 1, Tandang Sora, Quezon City 1116, The Philippines. Tel: +632 927-2482; E-mail: amadorcatacutan{at}yahoo.com
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
Introduction: In 1998, the Philippines’ Department of Health implemented the Quality Assurance Programme, known as the Sentrong Sigla (Centre of Vitality) Movement, starting with primary health care units. The Department established the National Objectives for Health in 1999, which set targets for health status and service coverage by 2004. The Movement certifies primary health care facilities that comply with its list of quality standards. Three years after implementation of the Sentrong Sigla Movement, the present study assessed it as an intervention for the delivery of health care services. Specifically, it evaluated the 2001 service coverage among certified facilities and compared it with that of non-certified facilities in the National Capital Region (Metro-Manila) of the Philippines, and related service coverage to the targets of the National Objectives for Health for 2001.
Methods: For the intervention group, the study randomly selected 82 of the 143 certified facilities (57.3%), with 88 of the 223 non-certified facilities (39.5%) serving as the control group. Using reliable and valid measurement indicator tools, data were collected on preventive health services programmes, curative programmes and monitoring programmes. To compare service coverage of the intervention and control groups, the data were analyzed using chi-squared tests, prevalence ratios, clustered sampling analysis and linear regressions of the rates.
Results: The overall 2001 service coverage shows that certified facilities had significantly less success in the preventive and monitoring programmes than the non-certified facilities, but were not significantly different in the curative programmes. Neither type of facility reached the targets of the 2001 National Objectives for Health for preventive programmes. After adjusting for clustering, the certified facilities showed significantly lower service coverage, compared with non-certified facilities, only for enrolling new acceptors to the Family Planning Programme and for water-supply testing in the Environmental Sanitation Programme.
Conclusion: Unlike previous studies, the results and analysis of the present study show that, generally, the Sentrong Sigla Movement had not improved the processes required to achieve better outcomes. Factors that could have contributed to the findings are described and strategies for improvement are recommended.
Key Words: quality assurance, primary health care, service coverage, health services, Manila, Philippines
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
Quality assurance is now being implemented not only in the business and industrial sectors, but also in the health sector. Quality assurance is a clinical and management approach that involves the systematic monitoring and evaluation of pre-defined and agreed levels of service provision (Higginson 1994, in Bowling 1997
: 7). Forsberg et al. (1992) have defined quality assurance in health services as an evaluation activity that assesses the quality of care against standards developed for structure, process and outcome of care. Structure–process–outcome is the proposed conceptual model of quality assurance for developing countries (De Geyndt 1995: 31). Structure (input) is needed to provide the services. Process (throughput) is the procedure or activity that transforms the inputs into services resulting in the provision of the services. Outcome (output) is the impact of health services on the health status of patients and community. Quality management can help an organization to achieve better outcomes with fewer resources, thus, an increase in effectiveness (appropriateness/quality of care) coupled with greater efficiency (cost containment) (Counte et al. 1995).
The assessment of quality is the action taken to establish the effectiveness and efficiency of quality assurance (McLaughlin and Kaluzny 1994: 54) to improve the outcome of the programme (Roemer and Montoya-Aguilar 1988: 13) and to evaluate the impact of health services on the population (St Leger et al. 1992: 1–2). As defined by the World Health Organization, evaluation is a means of analyzing activities and identifying successful aspects of a programme as well as any deficiencies that are amenable to corrective action (WHO 1984: 15). In evaluating quality, the organization searches for direct or indirect evidence to prove that it chose and applied the best approach of care in the most skilful way (Graham 1995: 201–3).
In the Philippines, the health services were devolved from the national government to the local government units as mandated by law in 1992. With the decentralization of health services and the meagre budget allocation to health, the Department of Health developed and established a strategic framework and plan for the delivery of quality health care services, starting with the primary health care units. In partnership with the local government units, the Quality Assurance Program, known as the Sentrong Sigla (Centre of Vitality) Movement, was initiated in 1998 (Department of Health 2000). This programme was developed in response to an analysis of the Philippine health situation; a large number of the population suffer from poor health because of lack of access to health facilities, poor quality of health care, high cost of health services and medicine, and deficient coverage by effective public health and primary care services. The general objective of the programme is to develop a better collaboration between the Department of Health, which provides the technical and financial assistance for health care, and the local government units, which develop the health systems and implement the health programmes. The ultimate goal of the programme is a sustainable health sector reform that will upgrade the standards and quality of health care service delivery for all sectors.
To improve the quality of services in primary health care facilities, the Quality Assurance Programme set quality standards that a facility needs to comply with in order to be certified by the Sentrong Sigla Movement (SSM). The Movement assesses eight quality standards: (1) infrastructure/amenities; (2) health services; (3) attitude/behaviour of health workers; (4) human resources; (5) equipment; (6) drugs/medicine/supplies; (7) health information system; and (8) community intervention.
The infrastructure/amenities standards look at the physical condition of facilities, as well as waiting times and accessibility of the clinic for patients unable to attend during regular clinic hours. The health services standards enumerated 11 health programmes that should be functioning at the facility at all times. These include the expanded programme of immunization, disease surveillance, control of acute respiratory infections, control of diarrhoeal diseases, micronutrients supplementation/nutrition, tuberculosis control, STD/AIDS prevention and control, cancer control, and maternal care. All of these health programmes are required to have specific criteria, conditions, equipment and supplies to qualify as providing quality services.
The standards on attitude and behaviour of the health workers require proper conduct by staff in dealing with patients, and basic training courses. With the human resources standards, the staff undergo a staff development programme and competency-based assessments. The equipment standards enumerate the basic instruments and equipment needed in a facility. Essential drugs and supplies are identified in the drugs/medicines and supplies standards. The health information system standards deal with the referral system and documents required. Finally, the community intervention standards emphasize the role of community health volunteer workers, community organization and community participation.
Every year, each local government unit of the Philippines voluntarily nominates to the SSM its accredited primary health care units that conform to and maintain the quality standards set by the Movement. Accredited health care facilities are authorized by the Department of Health to provide health care services to the populace, based on certain operational requirements. After nomination, the regional team of the SSM conducts visits to assess or monitor compliance with the quality standards and certifies those facilities that do comply. Patients can expect quality health services from these certified facilities. The SSM re-assesses and monitors recognized facilities periodically to ensure that standards are maintained. Out of 366 primary health care units within the National Capital Region, the SSM had certified 143 facilities as of December 2000. Seventeen local government units comprise the National Capital Region, of which 15 are cities and two are municipalities, as at 2001.
In support of ‘Health for all Filipinos’, the Department of Health of the Philippines developed the National Objectives for Health in 1999, which set targets for health status and service coverage by the year 2004 (Department of Health 1999). The National Objectives for Health aimed to reduce morbidity, mortality, disability and complications from certain diseases like diarrhoea, pneumonia, malnutrition, tuberculosis and sexually transmitted diseases, as well as to eliminate diseases like measles, tetanus, diphtheria and poliomyelitis. Each prioritized disease identified by the National Objectives for Health is included in the disease-specific control and prevention programme, which has a main goal, health status objectives, risk reduction objectives, and services and protection objectives. Realistic objectives and quantifiable targets are set which should lead to the improvement of the outcome and impact of the programme, taking into account the limited resources available. Furthermore, the National Objectives for Health promote a healthier lifestyle, the health and nutrition of families, and environmental health and sustainable development.
The National Statistics Office provides each local government unit with the projected yearly population that will fall under the unit's jurisdiction, and each facility, whether certified by the SSM or not, computes its target population for every programme included in the health services. Target populations are estimated from the catchment population and are derived from empirical formulae determined by the Department of Health. The formulae take into account the national prevalence of cases and the percentage of poor, who are the target beneficiaries of the services. Thus, there are target populations for the number of married couples, children under 5 years, pregnant mothers, etc. These target populations are used by primary health care facilities, whether certified or not, as guides to project their expected workload and as tools to measure coverage.
Study design
The present study evaluates the SSM as an intervention to improve health service coverage. In this context, service coverage refers to the number of cases served by a particular health programme over the eligible population (target population) for that programme. It does not necessarily address the other important dimensions of the quality of health facilities, such as patient satisfaction, technical quality, equity, effectiveness and efficiency. Specifically, it assesses and compares health service coverage of the quality-certified and non-certified facilities within their catchment areas, in terms of inputs and processes at one point in time within Metro-Manila. Moreover, it relates the health service coverage to the targets of the National Objectives for Health for 2001.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
Referring to the set of eight quality standards of the SSM, the author identified relevant standards together with their indicators from sources of the World Health Organization and the World Bank (WHO 1981
, 1984; Roemer and Montoya-Aguilar 1988; De Geyndt 1995; and World Bank, Health Population and Nutrition websites1). These tools were used to assess quality assurance in primary health care, to evaluate the health service coverage of primary health care units, to monitor progress towards ‘Health for All’ by the year 2000; and for monitoring and evaluation of health programmes to improve services. From these sources, the standards and indicators relevant to the standards of the SSM were collated into one measurement tool, the Health Service Coverage Tool. To assess the applicability of the Health Service Coverage Tool to the Philippine setting, the author consulted a group of five experts with experience of quality assurance programmes in the Philippine health care sector. The members of the panel consisted of the founding president and the treasurer of the Philippine Society for Quality Healthcare, the current president of the Philippine Council on the Accreditation of Healthcare Organizations, a professor of the College of Public Health of the University of the Philippines, and a quality director of one of the leading private hospitals. The author provided each expert with the following: (1) a copy of the quality standards of the SSM for rural health units/health centres; (2) the Health Service Coverage Tool; (3) an evaluation sheet to analyze the applicability, measurability, and appropriateness of each indicator for every quality standard of the SSM. On the evaluation sheet, the expert could choose to retain, delete or modify the indicator. An endorsement of an indicator by a simple majority from the pool of experts retained, deleted or modified the indicator.
Due to the exclusion criteria of the study, the panel deleted from the Health Service Coverage Tool the standards that are not related to the health services of the SSM. All five members of the expert group agreed to delete five of the eight standards in the Health Service Coverage Tool. This included the standards on infrastructure/amenities, human resources, equipment, drugs/medicines/supplies, and health information systems. While the standards for attitude/behaviour of health workers and community intervention may indicate health service quality, they overlap in the definition of service standards, and, subsequently, four of the five members deleted these two standards as well. Therefore, the group retained only the indicators for the quality standards on health services, to form the Revised Health Service Coverage Indicator Tool.
The Revised Health Service Coverage Indicator Tool includes the following indicators:
- Expanded Programme on Immunization (EPI) – the number of children under 1 year of age who are fully immunized over the target population of children under 1 year of age.
- Family Planning Programme (FPP) – the number of new acceptors/couples protected by family planning methods over the target population of eligible couples.
- Maternal Care Programme (MCP) – the number of women who received three or more antenatal care consultations over the target population of pregnant mothers; the number of pregnant women who are protected by tetanus toxoid (TT2+) over the number of women who received three or more antenatal care consultations.
- Control of Acute Respiratory Tract Infection (CARI) – the number of patients with mild to moderate pneumonia attended in the clinic over the total number of patients with pneumonia.
- Control of Diarrhoeal Diseases (CDD) – the number of cases of diarrhoea in children in which dehydration was looked for and treated over the number of children attended with diarrhoea.
- Tuberculosis Control Programme (TCP) – the number of cases who submitted three or more sputum samples over the number of all tuberculosis cases diagnosed.
- STD/AIDS Control Programme (SACP) – the number of sexually transmitted disease (STD) patients treated over the number of suspected STD patients.
- Under-5 Nutrition Programme (UNP) – the number of children under 5 years recorded with a growth chart over the target population of children under 5 years.
- Cancer Control Programme, Cervical Cancer Screening Programme (CCSP) – the number of women aged 18–65 years old receiving a Papanicolaou smear at an interval appropriate for their age over the target population of women in the 18–65 age group.
- Environmental Sanitation Programme (ESP) – the number of households tested for safe water sources over the total number of households.
The inter-rater reliability of the expert group, determined as the members’ percentage of agreement on the deletion of standards from the Health Service Coverage Tool, was found to be 80%. The panel of experts relied on the face and content validity of the instrument as reflective of what the tool purports to measure. Face or logical validity is the extent to which the question is logically constructed so it can be answered. Content validity is the extent to which the item being measured covers the range of phenomena relevant to the exposure of interest. In the study, the exposure of interest is the health service coverage of the facilities.
To gain feedback on the clarity of instructions and responses, the author pre-tested the measurement tool on 5% of the total primary health care facilities in Metro-Manila. Data for the Revised Health Service Coverage Indicator Tool were collected from the Field Health Service Information System of each facility. The Field Health Service Information System is a monthly, quarterly or yearly summary sheet of all the programmes of the facilities. A data collection sheet recorded all the data according to specified instructions. The pre-testing ensured that the target group understood the questions in the way intended by the author. The results from the pre-tested facilities were excluded from the final analysis. Subsequently, the author carried out a pilot study on 10% of the population sample. The pilot study established the observed proportion of service coverage in each group and determined the final sample size for the present study. The observed proportion was 89% overall health service coverage for the SSM-certified facilities (intervention group) against 72% for the non-certified facilities (control group). The predetermined significance level to test the null hypothesis is 0.05 (confidence interval of 95%) with a power probability (i.e. the chance of showing a significant difference between the sample proportions) of 80%. Using a software program, the statcalc.exe of EpiInfo Version 5, December 1990, the calculated total sample size was estimated to be at least 154, divided equally between the intervention and control groups. The results of the pilot testing were included in the final analysis.
In selecting the sample health service coverage to represent the certified (intervention) and non-certified (control) groups, several factors were considered. Both the intervention and control groups were selected from the same well-defined database from which the random sample of all cases arising during the study period was selected. Primary health care facilities of the local government units were selected randomly to represent the intervention and control groups. To be eligible, the sample facilities had to be located in Metro-Manila. For the SSM-certified facilities, their certification had to have been maintained for at least 2 consecutive years (i.e. 2000 and 2001), while the non-certified must have rendered their services for at least 2 years. The list of facilities in the intervention group was separated from the control group and the author randomly selected samples from both groups.
The author collected data from the randomly selected facilities on their accomplishments and target population for the preventive programmes (EPI, FPP and MCP); the curative programmes (CARI, CDD, TCP and SACP); and the monitoring programmes (UNP, CCSP and ESP). Programmes found to have incomplete or missing data for the year 2001 were excluded from the analysis. After checking the data for biases and missing values, the author edited, coded and categorized the collected quantitative data, presenting it in table and graph formats. The collected data were converted into annual percentage service coverage for each health services programme included in the SSM.
The tables were used to compare the annual health service coverage for each type of facility for every health service programme. The number of facilities included or excluded in the evaluation varies from programme to programme. Facilities with complete data on a particular health services programme for the year 2001 were included in the evaluation, while those with missing or incomplete data were excluded. The number of cases attended for each variable during the year was enumerated in the ‘achieved’ column, which was divided by the target population for each health programme to get the percentage. The graphs, on the other hand, compared the service coverage of the certified and non-certified facilities against the acceptable levels of service coverage (targets) of the National Objectives for Health for 2001.
The study measured and compared the 2001 annual health service coverage between the SSM-certified and non-certified facilities. Appropriate statistical techniques were used to test the null hypothesis. Relative ratios, which measure the association in terms of the ratio of the proportions, were determined to compare the overall proportions in the annual health service coverage. A further analysis adjusted for clustering in the sample. There were a maximum of 82 clusters (i.e. primary health care units) in the SSM-certified group and 88 clusters in the non-certified group. Comparing the proportions in clustered samples would require independent samples; otherwise, the analysis might result in very narrow confidence intervals and small p values, producing spurious significant differences (Bland 2000: 179–81). In the analysis of clustered samples, a summary statistic (rate) for each cluster was constructed and, using the two-sample t method, the mean rates were compared between the two groups. In clustered analysis, the power of the study is lost (Bland 2000: 344) and, therefore, the power of the test, as well as the size of the effect, was computed. Likewise, linear regressions of the rates were estimated, adjusting for cluster size.
|
Results |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
Of 366 facilities, 170 were included in the study, of which 82 were certified and 88 non-certified. This represented 57.3% of the total SSM-certified and 39.5% of non-certified facilities. Based on the census and yearly projections of the National Statistics Office, the sample facilities served a total population of 5.06 million in 2001, or an average of one SSM-certified facility for every 36 207 population, and one non-certified facility for every 23 775 population (Table 1).
|
Health service coverage of the preventive programmes
Table 2 compares the overall 2001 annual achievements of the preventive programmes between the non-certified and SSM-certified facilities. The SSM-certified facilities achieved significantly lower health service coverage of their target population compared with non-certified facilities in fully immunizing children less than 1 year of age, enrolling new acceptors to the family planning programme, attaining more than three pre-natal visits for every pregnant mother, and fully immunizing pregnant mothers with tetanus toxoid (TT2+).
|
Figure 1 presents the 2001 annual health service coverage of the two facility groups and compares these percentages with the 2001 targets of the National Objectives for Health in the delivery of the preventive programmes. If the 2004 target of the National Objectives for Health is to increase to 95% (from the 1997 baseline level of 90%) the coverage of full immunization of children before their first birthday, then the acceptable level in 2001 for this target is about 92%. The SSM-certified and non-certified facilities were 15% and 4% short, respectively, of this target level. For the contraceptive rate, the 2004 target of the National Objectives for Health is to increase the rate to 54% (baseline: 46.5% in 2000); thus, the acceptable rate for 2001 is 48.4%. The SSM-certified facilities had enrolled 23% less than the acceptable rate in 2001, compared with 1.6% more for the non-certified facilities. In the MCP, the national target for 2004 is to increase to 80% the percentage of pregnant women having three pre-natal visits to professional health providers (baseline: 77% in 1998 with at least three pre-natal visits). In contrast to the acceptable target of 78.2% for the year 2001, the SSM-certified facilities had achieved only 52.5%, compared with 73% for non-certified facilities. The National Objectives for Health did not specify the target for immunization with tetanus toxoid but said that mass immunization should be conducted on women aged 15 to 44 years, with a maximum of five doses of tetanus toxoid. It could be speculated that for pregnant mothers, the coverage should be 100%.
|
Health service coverage of the curative programmes
Table 3 compares the 2001 health service coverage for the curative programmes in the non-certified and SSM-certified facilities. There were no significant differences in coverage between the certified and non-certified facilities in treating mild to moderate pneumonia and in managing diarrhoea cases. Procedural policy states that only those with mild to moderate pneumonia should be treated in primary care facilities; patients suspected of severe to very severe pneumonia should be referred to hospital. Certified facilities achieved significantly higher results in collecting three or more sputum smears for the diagnosis and monitoring of tuberculosis cases, compared with non-certified facilities.
|
Figure 2 illustrates the annual health service coverage of the facilities for the curative programmes and compares the coverage to the target levels of the National Objectives for Health for 2001. Based on the 2004 target of the National Objectives for Health, the management of diarrhoeal cases with oral rehydration therapy should be increased to 80% (baseline: 64% in 1998). The target for 2001 is 77.6%, which the SSM-certified facilities had surpassed by an additional 22%. The National Objectives for Health do not specify a target for sputum collection within the TCP, apart from stating that the percentage of contacts by smear-positive cases with a health provider for diagnosis and treatment should be increased. However, the facilities should be performing close to 100% in collecting three or more sputum samples from patients.
|
For the SACP, the data were collected from 39 SSM-certified and nine non-certified facilities. SSM-certified facilities appear to have diagnosed more cases of sexually transmitted diseases than non-certified facilities (Table 3). However, each local government unit in the National Capital Region has its own central clinic for sexually transmitted diseases where suspected cases are referred for diagnosis and treatment. Most of these central clinics are SSM-certified. The author tried to determine the actual number of STD/AIDS patients from each referring facility, but this proved impossible because the central clinics have consolidated their STD/AIDS data. Since there is a selection bias, the study did not further evaluate the data for the SACP.
Health service coverage of the monitoring programmes
The monitoring programmes include the UNP, CCSP and ESP. Their coverage levels for 2001 are shown in Table 4. In all programmes, the SSM-certified facilities achieved significantly lower health service coverage than non-certified facilities.
|
Figure 3 compares the 2001 annual health service coverage between the SSM-certified and non-certified facilities. Aside from the CCSP, there are no specific targets for the other monitoring programmes in the National Objectives for Health and, therefore, the figure does not include a comparison of the achievements of the facilities with targets for the UNP and the ESP. The target of the National Objectives for Health for the CCSP is to increase the proportion of women (age 18–65 years) having a Pap smear test every 3 years to 50% by the year 2004 (baseline: 27% in 1989). Therefore, the acceptable level of health service coverage in 2001 should be 36%. This level was not achieved by either the SSM-certified or the non-certified facilities.
|
Clustered sampling analysis
When the data are adjusted for clustering, the results still show the non-certified facilities performing significantly better than the SSM-certified facilities in enrolling new acceptors to the FPP and in water-supply testing for the ESP (Table 5).
|
Using the grouped data, linear regressions of the proportions of health service coverage (dependent variable) on certification status and target population (independent variables) were done:
 |
From the above analyses, the null hypothesis, which states that there is no difference in the health service coverage between SSM-certified primary health care facilities and non-certified facilities, is rejected for the enrolment of new acceptors to the FPP and testing of water supply for the ESP. However, it is accepted for the processes of the other programmes.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
The Sentrong Sigla Movement has set quality standards, with an extensive list of inputs and processes, that certified facilities should comply with, and the National Objectives for Health have set targets for health status and service coverage for the years 2000 to 2004 in order to improve the quality of services in primary health care facilities (Department of Health 1999
, 2000). From the preceding analyses, the SSM-certified facilities performed significantly less well than the non-certified facilities in enrolling new acceptors to the FPP and in testing water supply for the ESP in 2001, but there were no significant differences in coverage for the other health service programmes compared with non-certified facilities. However, the study considered only crude estimates of these factors – whether or not the facilities were certified. The study did not endeavour to demonstrate the changes brought about by the intervention nor created a post-hoc comparison of the intervention and non-intervention sites (e.g. by controlling factors to show how the intervention makes a difference).
The results and analysis of the present study are inconsistent with the conclusions of previous studies that quality assurance improves processes to achieve better outcomes, for example studies by Palmer et al. (1985), Zeitz et al. (1993), Kipp et al. (1994), Omaswa et al. (1997), Solberg et al. (1998). Several factors may have accounted for the inconsistency. These include the quality of enumeration of data, the quality standards themselves, structural constraints and preference of health care providers.
A possible factor that could have contributed to the findings may relate to issues of data quality, with errors in the enumeration of cases and in the estimation of target populations. This could be a limiting factor in measuring health service coverage and could bias the results toward to the null hypothesis. In the FPP, for example, the enumeration of eligible couples included only married couples, excluding couples who were living together but not married. Because of this, some rates exceeded 100%; however, these were constrained to less than 100% during the analysis. The estimation of the target population, which considered the national prevalence of cases and the percentage of the poor, is not based on actual head counts. There could be in-migration or out-migration at some locales in the community, which could have increased or decreased, respectively, the population of the local government unit and, as a result, the target population is not reflective of the true index. Unless there is a better computation of the target population that approximates the true index, errors in the estimation of the target population may be difficult to avoid.
Looking at the list of quality standards in the section of health services, the list suggests that the standards are mostly focused on inputs or structure. McLaughlin and Kaluzny (1994: 54) have stated that adequate inputs alone do not ensure good outcomes as compared with process measures. Most likely, the management approach used by the SSM is what Omaswa et al. (1997) labelled ‘management-by-results’, where specific targets for health programme interventions are set without identifying the process by which the targets will be achieved.
Some structural constraints (such as manpower, finance and supplies), identified by Gilson et al. (1995), may also have played a role. As shown in Table 1, certified facilities serve a larger catchment population than non-certified facilities. Each type of facility is manned, on average, by a doctor, a nurse and two midwives. Because there is no difference in staffing pattern for different population sizes, the resulting staff:population ratios differ between the two groups of facilities, favouring the non-certified facilities. As a result, the population coverage of inputs, rather than the quality of inputs, could account for the differences. The direction of this bias is towards the alternative hypothesis that certified facilities would do worse. This uneven population coverage has further implications for the output of staff. Due to patient overload in SSM-certified facilities, staff may not have been able to deliver the health care programmes adequately. Added to this are the limited clinic sessions allotted for carrying out the programmes and the other competing health care providers who are not captured in the public information systems.
A further reason for the discrepancy may be that the certified facilities expended considerable effort on the certification preparation and processes at the expense of health service coverage. Certification itself does not guarantee a positive effect on the coverage of most services. A negative effect of certification is the lack of local support and local inputs from the local government units once the facilities are certified. There could also be the presence of the well-known tension between providing care that meets the patient's agenda (patient-centred care) and structured care based on evidence-based guidelines. The latter explanation may merit further qualitative research.
Moreover, it could be that certified facilities are delivering effective health programmes, reducing population risks so that fewer cases are seen in the facilities. This would result in a low population coverage that would bias against the certified facilities. It could also be that certified facilities may have better inputs, but the community perceives the quality or value negatively. Since the SSM is a recent phenomenon, it may be that there is a lagged effect, and that more time is needed to see if changes in inputs and processes lead to higher utilization and coverage.
Lastly, the measures of certification and/or health service coverage may not be reliable or valid, leading generally to bias towards the null hypothesis. A number of facilities were excluded from the analysis because of missing data. For the preventive and curative programmes, a range of 0–5% was lost for the non-certified facilities compared with a range of 0–11% for the certified facilities. This may have less of an effect on the analysis compared with the monitoring programmes, which incurred losses of 20–75% in the non-certified facilities and 16–66% in the certified facilities, resulting in bias against the certified facilities.
|
Conclusion and recommendations |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
The study compared health service coverage among SSM-certified facilities and non-certified facilities on preventive health programmes (expanded programme of immunization, family planning and maternal care), curative health programmes (control of acute respiratory infections, diarrhoeal diseases, and tuberculosis) and monitoring health programmes (under-5 nutrition, cervical cancer screening and environmental sanitation). Based on crude estimates, the overall 2001 health service coverage has shown that the performance of the SSM-certified facilities in Metro-Manila was significantly lower than that of the non-certified facilities for the preventive and monitoring programmes, but the SSM-certified facilities faired better on the curative programmes. Since the sample population indicated clustering of the data, coverage was also evaluated using clustered sampling analysis. The analysis revealed that the mean percentage of health service coverage for SSM-certified facilities was significantly lower than for non-certified facilities in enrolling new acceptors to the FPP and for the testing of water supply in the ESP. Because the study used crude estimates, this would warrant further investigation.
The analysis of the Quality Assurance Programme as an intervention to improve outcomes did not produce the expected results. However, this does not mean that the programme has failed. It is still in its infancy. A focus on the whole system, where the relationships of the inputs, processes and outputs are determined, as well as implementing continuous quality improvement activities, is necessary to address the factors identified in the previous section. In order to improve the health service coverage, issues that need to be addressed include the quality of data collection, the quality standards themselves and some structural constraints.
It is vital for the facilities to have reliable estimates of the target population for each health service programme, instead of relying on the empirical formula advocated by the Department of Health. The task of determining a reliable catchment population and the target population for each health programme may be a tedious process, but in the end, the collected data will be reflective of the true catchment population and target population indexes. For instance, in the FPP, couples who live together but who are not married should be included in the enumeration of eligible couples (i.e. the target population). The formula of the Department of Health states that married couples are the target population in the FPP, but, in practice, the facilities serve all couples regardless of their marital status. Because of this, some study facilities achieved accomplishment rates of more than 100%.
It is also necessary for facilities to have a complete database. Some facilities in this study were excluded from the analysis because of missing or incomplete data. While a statistical significance was determined in some results, the power of the test was diminished. During the data collection, the author found that the data in some facilities were not filed properly or handled safely.
The quality standards of the SSM are mostly focused on structural requirements, but need also to incorporate the processes, i.e. how the objectives and targets will be achieved. It is helpful to identify all the processes involved by developing a flowchart of the system, where the processes are identified from the input stage to the output stage. Any deviation within the system would reflect a failure of the whole system. This deviation is the root cause of the problem and appropriate actions to correct the deviation and prevent it from occurring might need to be determined.
Population coverage also needs to be addressed. There is discrepancy in the population served by certified and non-certified facilities, a factor identified in the low service coverage of the certified facilities. With an average of one doctor for a total population of 36 000 in areas served by certified facilities, compared with one doctor per 24 000 population in areas served by non-certified facilities, there is a need to increase the number of staff in certified facilities. If employing new staff is not possible because of financial constraints, the local government unit might consider redistributing the allotted population more equally, such that each facility covers an almost equal number of population.
The present study has offered a crude picture of the health service coverage of the Quality Assurance Programme, the Sentrong Sigla Movement, among primary health care units in Metro-Manila, the Philippines. Whilst the study shows whether the input and process dimensions of quality are related to the coverage dimensions, the repeatability and validity of the health service coverage or certification measures need careful consideration, i.e. whether the items measured are reliable indicators and truly representative of health service coverage. Future research may investigate the barriers to effective implementation of the programme, with analytical studies on the most efficient and effective processes in the health care services coverage.
|
Biography |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
Amador R Catacutan is an adviser on local health systems development with German Technical Cooperation (GTZ) – Philippines. Previously he was a postgraduate lecturer at the University of Santo Tomas (Graduate School), Philippines, and Executive Director of the Philippine Council on Accreditation of Healthcare Organizations (PMA Building, North Avenue, Diliman, Quezon City, Philippines). He has a Master of Philosophy in International Public Health (University of Sydney, Australia), a Master of Hospital Administration (Ateneo de Manila University, Philippines) and is a Doctor of Medicine and Surgery (University of Santo Tomas, Philippines).
|
Endnotes |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
1World Bank, Health Population and Nutrition websites: [http://www1.worldbank.org/hnp/] and [http://www1.worldbank.org/hnp/tools.asp]
|
References |
|---|
|
TopAbstractIntroductionMethodsEndnotesResultsDiscussionConclusion and recommendationsBiographyReferences |
|---|
Bland M. 2000. An introduction to medical statistics. third edition. New York: Oxford University Press.
Bowling A. 1997. Research methods in health: investigating health and health services. Buckingham: Open University Press.
Counte M, Glandon G, Oleake D, Piltill J. 1995. Improving hospital performance: issues in assessing the impact of TQM activities. Hospital and Health Services Administration 40: 80–94.
De Geyndt W. 1995. Managing the quality of health care in developing countries. World Bank Technical Paper Number 258. Washington, DC: World Bank.
Department of Health. 1999. National Objectives for Health, Philippines, 1999–2004. Manila: Department of Health.
Department of Health. 2000. Sentrong Sigla. Strategic Framework and Plan, Year 2000–2004. 2nd Printing. Manila: Department of Health.
Forsberg BC, Barros FC, Victoria CG. 1992. Developing countries need more quality assurance: how health facility surveys can contribute. Health and Policy Planning 7: 193–6.
Gilson L, Magomi M, Mkangaa E. 1995. The structural quality of Tanzanian primary health facilities. Bulletin of the World Health Organization 73: 105–14.
Graham NO. 1995. Quality in health care: theory, application and evolution. Gaithersburg, MD: Aspen Publishers.
Kipp W, Kielmann AA, Kwered E, Merk G, Rubaale T. 1994. Monitoring of primary health care services: an example from Western Uganda. Health Policy and Planning 9: 155–60.
McLaughlin C, Kaluzny A. 1994. Continuous quality improvement in health care. Gaithersburg, MD: Aspen Publishers.
Omaswa F, Burnham G, Baingana G, Mwebesa H, Morrow R. 1997. Introducing quality management into primary health care services in Uganda. Bulletin of the World Health Organization 75: 155–61.
Palmer RH, Louis TA, Hsu LN et al. 1985. A randomized controlled trial of quality assurance in sixteen ambulatory care practices. Medical Care 23: 751–70.
Roemer MI, Montoya-Aguilar C. 1988. Quality assurance and assessment in primary health care. WHO Offset Publication no. 105. Geneva: World Health Organization.
Solberg LI, Kottke TE, Brekke ML. 1998. Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial. Preventive Medicine 27: 623–31.
St Leger AS, Schneider H, Walsworth-Bell JP. 1992. Evaluating health services effectiveness. Milton Keynes: Open University Press.
WHO. 1981. Development of indicators for monitoring progress towards Health for All by the Year 2000. ‘Health For All’ Series No. 4. Geneva: World Health Organization.
WHO. 1984. Evaluating primary health care in South-east Asia. SEARO Technical Publications Series No. 4. New Delhi: World Health Organization.
Zeitz PS, Salami CG, Burnham G et al. 1993. Quality assurance management methods applied to a local-level primary health care system in rural Nigeria. International Journal of Health Planning and Management 8: 235–44.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||