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 .
Improving pneumonia case-management in Benin: a randomized trial of a multi-faceted intervention to support health worker adherence to Integrated Management of Childhood Illness guidelines
Background Pneumonia is a leading cause of death among children under five years of age . The Integrated Management of Childhood Illness strategy can improve the quality of care for pneumonia and other common illnesses in developing countries , but adherence to these guidelines could be improved . We evaluated an intervention in Benin to support health worker adherence to the guidelines after training , focusing on pneumonia case management . Methods We conducted a r and omized trial . After a health facility survey in 1999 to assess health care quality before Integrated Management of Childhood Illness training , health workers received training plus either study supports ( job aids , non-financial incentives and supervision of workers and supervisors ) or " usual " supports . Follow-up surveys were conducted in 2001 , 2002 and 2004 . Outcomes were indicators of health care quality for Integrated Management-defined pneumonia . Further analyses included a graphical pathway analysis and multivariable logistic regression modelling to identify factors influencing case-management quality . Results We observed 301 consultations of children with non-severe pneumonia that were performed by 128 health workers in 88 public and private health facilities . Although outcomes improved in both intervention and control groups , we found no statistically significant difference between groups . However , training proceeded slowly , and low- quality care from untrained health workers diluted intervention effects . Per- protocol analyses suggested that health workers with training plus study supports performed better than those with training plus usual supports ( 20.4 and 19.2 percentage-point improvements for recommended treatment [ p = 0.08 ] and " recommended or adequate " treatment [ p = 0.01 ] , respectively ) . Both groups tended to perform better than untrained health workers . Analyses of treatment errors revealed that incomplete assessment and difficulties processing clinical findings led to missed pneumonia diagnoses , and missed diagnoses led to inadequate treatment . Increased supervision frequency was associated with better care ( odds ratio for recommended treatment = 2.1 [ 95 % confidence interval : 1.1 - 3.9 ] per additional supervisory visit ) . Conclusion Integrated Management of Childhood Illness training was useful , but insufficient , to achieve high- quality pneumonia case management . Our study supports led to additional improvements , although large gaps in performance still remained . A simple graphical pathway analysis can identify specific , common errors that health workers make in the case-management process ; this information could be used to target quality improvement activities , such as supervision ( Clinical Trials.gov number NCT00510679 )
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 .