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Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers.

Primary health care facilities in every province of Afghanistan.

Composite scale measuring the quality of clinical processes in four areas: patient histories, physical examinations, communication and time spent with patient.

No difference in service quality was observed between male and female providers or between male and female patients, but when both the provider and patient were female quality was much higher. Overall, the quality of care at non-governmental organization and government-managed health facilities did not differ, but the poor received higher quality care at non-governmental facilities than at government facilities. Doctors provided higher quality care than lower level providers. Provision of six or more supervisory visits in the last 6 months was associated with higher service quality. Training doctors in integrated management of childhood illness was not associated with quality, but when lower level health workers received such training the quality of patient–provider communication was higher. Other recurrent inputs and geographic remoteness are not associated with the quality of care provided.

The government's strategy to form partnerships with non-governmental organizations has led to higher quality of care provided to the poor. This represents a promising start in the reconstruction of Afghanistan's health system and provides useful evidence to other countries striving to increase access to quality care for the poor.

The framework was developed following an iterative process that combined expert consultation and group meetings with a narrative review of existing frameworks, as well as trends in health management and organizational theory.

Our conceptual framework for primary care has two domains: structural and performance. The structural domain describes the health care system, practice context and organization of the practice in which any primary care organization operates. The performance domain includes features of health care service delivery and technical quality of clinical care.

As primary care evolves through demonstration projects and reformed delivery models, it is important to evaluate its structural and organizational features as these are likely to have a significant impact on performance.

Prospective study over two months.

Five hundred and ten-bed university paediatric hospital.

In Robert Debré Hospital physicians generate drug orders online using a computerized physician order entry system that also detects drug–drug interactions in real time. We analysed the relevance of a sample of alerts overridden by physicians.

We analysed a sample of 613 overridden alerts. We defined three categories of overridden alerts: informational errors (35); system errors (244) and accurate alerts (334). Two reasons account for 40% of false-positive alerts: an inability of the system to recognize real conflicts between drug treatments and guidelines stating that the two drugs can be used together, because the benefit outweighs the risk of side effects due to the drug–drug interaction.

We created a classification of overridden alerts, in the context of computerized physician order entry system coupled with a drug–drug interaction detection system. There is clearly room for improvement in the development of drug–drug interaction software. This classification should make it possible to break this work down into smaller tasks, making it possible to decrease the sensitivity to background noise of drug–drug interaction detection systems.

Pre–post-descriptive study of 14 hospitals in Ethiopia.

Six regions and two city administrations in Ethiopia.

Hospital leaders and management mentors in participating hospitals.

In collaboration with the Ministry of Health and the Clinton HIV/AIDS Initiative, we implemented a countrywide quality improvement initiative in which 24 mentors with hospital administration experience were placed for 1 year in Ethiopia to work side-by-side with hospital management teams. We also provided a professional development course to enhance quality improvement skills.

Presence of 75 key management indicators; reported management skills of hospital leaders by the mentors.

In pre–post analysis, we found improvement in 45 of the 75 (60%) key management indicators between August 2006 and May 2007. The changes reflected a total of 105 management indicators improved across the 14 hospitals, which equates to a per-hospital mean of 7.5 (standard deviation 5.9) improvements. Reported management skills of hospital leaders improved in several management domains, although their reported confidence in these skills remained largely unchanged.

Our findings indicate that quality improvement efforts can be effective in improving hospital management in developing countries. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished.

Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers.

Primary health care facilities in every province of Afghanistan.

Numerical scale of client perceptions of service quality.

Clients report relatively high levels of perceived quality in Afghanistan. Most of the variation that is explained relates specifically to the patient's interaction with the health worker and not to other health facility characteristics, such as cleanliness, infrastructure, service capacity and the presence of equipment or drugs. The strongest determinants of client-perceived quality identified are health worker thoroughness in taking patient histories, conducting physical examinations and communicating with patients. Being seen by a doctor and being from a household in the poorest quintile are also associated with higher perceived quality. For female patients, being seen by a female provider is associated with higher perceived quality, while for male patients time and money spent for travel to the health facility are negatively associated with perceived quality.

Clinical quality and client perceived quality appear to be mutually reinforcing, and efforts to improve health worker performance in taking histories, conducting exams and communicating with patients are likely to increase client perceived quality in this setting. Client perceptions of service quality assume additional importance in Afghanistan, where the perceived legitimacy of the government may depend partially on its ability to convince the population that it can deliver essential health services.