Regional determinants of quality of care for sick children: A multilevel analysis in four countries

The limited impact of increased access to care on improvements in health outcomes during the Millennium Development Goal era has been attributed, in part, to inadequate quality of care. We identified regional factors associated with health service quality for sick child care in low-income countries and examined whether provider factors interact with regional factors to affect the quality of care.

We conducted cross-sectional random intercept four-level linear regression using the most recent Service Provision Assessment and Demographic Health Survey data from four countries (467 from the Democratic Republic of Congo 2018, 2425 from Afghanistan 2018, 2072 from Nepal 2015, and 813 from Senegal 2017). The outcome variable was the service quality score for sick child care, which was measured as the percentage of clinically recommended tasks completed in the integrated management of childhood illness (ranging from 0 to 100). Regional factors were selected based on the High-Quality Health System Framework.

The service quality score was found to be positively associated with the proportion of large facilities (β = 8.61; P = 0.004) and the proportion of providers ranked in the top fifth for service quality score (β = 30.15; P < 0.001) in the region. We identified significant cross-level interactions between provider qualifications (β = -16.6; P < 0.001) or job descriptions (β = 12.01; P = 0.002) and the proportion of providers in the top fifth for service quality scores within the region. As the proportion of top-performing providers in a region increased, the increase in the service quality score was more pronounced among providers who were nonmedical doctors or did not have job descriptions than among their counterparts.

Our findings indicate that the quality of care for sick children in a region improves with a greater proportion of high-performing providers or larger facilities. Providers who are not medical doctors, or those who have specific job descriptions, tend to benefit more from the presence of these top-performing providers.