^IScientific Collaborator, Swiss Centre for International Health, Swiss Tropical Institute, Basel, Switzerland
^IIPublic Health Specialist, Swiss Centre for International Health, Swiss Tropical Institute, Basel, Switzerland
^IIICity Medical Officer of Health, Ministry of Health, Dar es Salaam, United Republic of Tanzania
^IVDirector, Swiss Tropical Institute, Basel, Switzerland

Keywords Prenatal care/standards/economics/organization and administration; Quality assurance, Health care; Quality of health care; Delivery of health care; Health personnel/standards; Urban health services; Public sector; Private sector; Socioeconomic factors; Comparative study; United Republic of Tanzania (source: MeSH, NLM).

Mots clés Soins prénatals/normes/économie/organisation et administration; Garantie qualité soins; Qualité soins; Délivrance soins; Personnel sanitaire/normes; Services santé milieu urbain; Secteur public; Secteur privé; Facteurs économiques; Etude comparative; République-Unie de Tanzanie (source: MeSH, INSERM).

Palabras clave Atención prenatal/normas/economía/organización y administración; Garantía de la calidad de atención de salud; Calidad de la atención de salud; Prestación de atención de salud; Personal de salud/normas; Servicios urbanos de salud; Sector público; Sector privado; Factores socioeconómicos; Estudio comparativo; República Unida de Tanzanía (fuente: DeCS, BIREME).

In recent years, many developing countries have been actively seeking to improve the outputs and outcomes of their health care delivery system by engaging in a process of reform. Important elements of health sector reform in the United Republic of Tanzania have been the promotion of the private sector and improvements in the quality of care delivered by both private and public providers (1). Private services can clearly fill gaps when public services are inadequate, but there is a need to assess the quality of the care that they are providing as there is often concern about their performance (2–4).

One study in Dar es Salaam in the early 1990s (5) judged that the quality of curative outpatient care offered by governmental and private providers was low. Private facilities as a whole performed better than government ones, but many of them carried out practices that did not fulfil the norms established by the government. Subsequently, substantial efforts were made to improve the quality of care in the public sector through the Dar es Salaam Urban Health Project; for example by upgrading the equipment of first-tier facilities, making drugs regularly available, and training health workers.

Quality can be assessed from the point of view of the users (perceived quality) or by using technical standards (quality defined by professionals). Donabedian (6–8) was one of the first to reflect upon quality, to operationalize the term, and to offer a framework for its definition based on three major attributes: structure, process, and outcome. "Structure" refers to the attributes of the settings where health care occurs (material, human and financial resources, and organizational structure); "process" denotes what is actually done in giving and receiving care; and "outcome" indicates the effects of care on the health status of patients and populations (morbidity and mortality levels). Most studies assessing quality of care have looked at curative services and at structural aspects and process attributes (9–11), at client satisfaction (12, 13), or at the relation between curative and preventive services (14).

The present study, carried out in Dar es Salaam in 1999, compared the quality of antenatal care offered by public and private providers at the first-tier level.

Dar es Salaam is the largest city in the United Republic of Tanzania and at the time of the study, in 1999, had around 2.5 million inhabitants. Private profit-making health services have been operating in Dar es Salaam since the early 1990s, and in 1999 there were more than 500 private clinics and hospitals, ranging from small clinics to referral hospitals offering relatively high-technology services such as ultrasonography. In the government regulations a distinction is made between private profit-making and voluntary sectors. Delineation between these categories is, however, difficult (5), and so this paper makes no further distinction between these different types of private providers.

Selection of the health facilities to be included in the study was based on the Tanzanian Health Management Information System. Selected providers had to satisfy the following criteria: offer mother and child health care (MCH) services; be first-tier facilities (district and referral hospitals of both private and public sectors were excluded); and have a minimum of ten daily attendances. Based on these criteria, 18 facilities in the public and 19 in the private sector qualified for inclusion. From these, eight were initially randomly chosen for each sector. Data were collected over two days, and all pregnant women attending were included. One public first-tier service was excluded since no woman attended it during the data-collection days. For the private sector, an additional provider was included in the sample because the attendance rate was low at one of the other private providers. The sample thus consisted of seven public-service and nine private-sector providers. A total of 166 women who attended the public facilities were interviewed and observed, and 188 who attended private ones.

Operational definition of quality of care, data collection and analysis

This study used a definition of quality of care based on the framework provided by Donabedian (7, 8). Since outcome is a consequence of care rather than a component of quality of care (15), it was not further assessed. The main focus was therefore on process attributes of quality, particularly provider-client interaction. Interpersonal conduct and technical aspects were considered separately. The definition of adequate or good quality was based on local standards (16, 17). Benchmarks formulated for inputs, laboratory examination and prophylactic and treatment approaches during antenatal care were critically reviewed and transposed into measurable elements each describing an attribute. As carried out in a similar study on structural aspects of quality of care (18), individual elements were weighted based on a professional judgement on what can be considered as a good medical or behavioural standard. Points were then allocated to these characteristics, which in turn allowed calculation of an overall score for each of the attributes.

A socioeconomic ranking was constructed with the help of a points system. A score was assigned to the household to which the women belonged. The composite revenue score was based on the housing situation of the woman's household: the number of rooms available and the level of crowding; the construction of the house; the availability of basic infrastructure (water, electricity); and ownership of means of transportation and household goods (refrigerator, television, radio). Scores between 0 and 3 were assigned for each of these characteristics and a total score between 0 and 30 was assigned to each woman's household.

Data was collected over the period June–August 1999 by two female fieldworkers. Data were entered and analysed using EpiInfo 6.04 software (Centers for Disease Control and Prevention, Atlanta, GA, USA). Logical checks helped to ensure the accuracy of data entry. Differences between the public and private sectors in the overall scores were compared using the Kruskal–Wallis test, a non-parametric test for independent samples.

The median age of the study women was 25 years, 9% being under 18 years of age, and 8% over 33 years of age. For 31% of the women it was their first pregnancy. For 12% of women the observation and exit interview were performed during their first visit to a health service, and for 17% during the second visit. The remaining women were attending for their third or a further visit. No significant differences in the obstetrical characteristics were found between women attending public or private providers.

Iron(II) sulfate and folic acid (FeFo) for anaemia prophylaxis were provided free to 72% of the women attending governmental services. In the private sector only 12% of women received FeFo free. If available, chloroquine was distributed without charge by public services, while 93% of women using private services had to pay for it. In the private sector all the women had to pay for registration and laboratory examinations, while in the public services, 79% of women attending had to pay for registration and 88% for diagnostic services. Pregnant women using private services not only had to pay more often than in the public sector, but the median charge per consultation was about six times higher (910 Tanzanian shillings (US$ 1.3)) than in the public sector (140 Tanzanian shillings (US$ 0.2)).

Structural attributes of quality

The training levels of the personnel working in the antenatal care services in the public and the private sector differed, with those working in the latter having higher qualifications. In the public sector nearly all consultations (88%) were performed by an MCH auxiliary (who has two years' training) and virtually none by a doctor. In the private sector 10% of consultations were carried out by a doctor or an assistant medical officer, 60% by a midwife or nurse, and only 30% by an MCH auxiliary. There was a clear relation between the qualifications of the staff and the quality of the service provided. The more highly trained personnel performed better in the technical aspects of quality, with the doctors and medical assistants carrying out investigations more often, such as checking the urine or controlling for oedema (results not shown).

In general, consultation times were short. One-fifth of the consultations lasted less than 4 min, one-half less than 6 min, and 81% less than 10 min. There was a relation between consultation time and the qualifications of the personnel; medical doctors and assistant medical doctors spent an average of 14 min on a consultation, twice as long as midwives, nurses and MCH auxiliaries. On the other hand, there was no relation between the duration of the consultation and the number of women going to a particular provider each day.

The present study indicated that the women visiting private facilities for antenatal care were socioeconomically better off than those using public ones and that they generally paid more for the services. Some women attending public services reported that usually they had to pay for all services, including prophylaxis and blood pressure measurements, but that on the day of the interview services were free. This indicates that the presence of interviewers introduced a bias and that the estimates in the public sector for the cost study were too low. A similar observation was made in Uganda (21). However, even if the cost of public services was underestimated, the cost of attending private antenatal care facilities is still higher.

The study showed that structural attributes of quality were generally satisfactory, and that they had improved in public facilities considerably since the early 1990s as a result of rehabilitation and a better availability of drugs. Both private and public facilities provided a reasonably good quality of care in terms of interpersonal aspects. The assessment of the quality of first-tier antenatal care services, based on Tanzanian national standards, has shown that neither public nor private providers are offering an adequate quality of care from the technical point of view, although private providers are performing better. Instructions given in official guidelines, for example concerning the dispensing of prophylactic drugs against anaemia or malaria, were not respected or diagnostic examinations were frequently not carried out. It is possible, however, that the process dimensions of quality of care were affected partially by measurement bias. Although observations by fieldworkers were made as discretely as possible and staff did not know in advance that the fieldworkers would visit, their presence possibly influenced the behaviour of health workers. For example, women might have been treated more courteously than usual. If so, general judgements on interpersonal and technical quality would be higher than under normal conditions. However, there is no reason to believe that this bias would alter the conclusions of the study with regard to process attributes of quality, nor the comparisons between the private and public sector.

Various authors have formulated concern about the quality of care provided by the private sector, and low quality treatment practices have been reported for various diseases (22, 23). This study pointed out that private providers for antenatal care were significantly better than public ones with regard to all attributes of quality under investigation. This is in line with other studies which have showed that private services can deliver adequate services in family planning or treatment of sexually transmitted diseases (24, 25).

There has been rapid growth in the private sector since new legislation on individual medical practice was introduced at the beginning of the 1990s. As a result, public providers increasingly have to compete for patients by offering services of adequate quality. Today, private health facilities account for more than 85% of health facilities in the city, and provide curative care for a majority of the population (20). Regulating and improving quality of care in the private sector presents an additional challenge in an already complex and difficult endeavour. Legislation on minimum standards is needed, as well as adequate public supervision to ensure its enforcement (26). However, such measures need to be accompanied by education and information campaigns to make sure that all those working in the private sector understand the minimum standards required. Education of clients about what minimum standards they should expect in return for the fees they pay could also play a role in influencing the private sector.

Quality of care is closely linked to the quality of the health services personnel. The study showed that the quality of performance was linked to the training level of the personnel (see also 9, 10). The fact that in the private sector staff were better qualified was one reason why quality was judged to be better in this sector. However, most first-tier services will continue to be provided by less well-qualified staff, particularly in the public sector. The reasons why health workers perform badly need to be investigated, and ways found to improve their performance. It needs to be established whether the problem is lack of knowledge, or whether workers are not able to translate knowledge into appropriate practices.

Approaches to improving quality of care should be based on regular quality assessments and additional operational research activities. The following are important components of such strategies (27): using an incremental approach introducing a few issues at a time and revisiting them regularly; and ensuring participation, choice, and ownership of every aspect of the strategy, while at the same time providing vision and direction. The latter component implies involving health staff at all levels of the health care system, as well as the community, through an active dialogue and sharing of decision making. The ultimate goal should then be "to create an environment of watchful concern that motivates everybody to perform better" (6).

We are very grateful to the women and health workers who kindly agreed to participate in the study. We would like to thank Jennifer Jenkins and Guy Hutton for advice and helpful comments during the writing of the document. The Swiss Federal Office of Education and Science provided financial assistance for this research through its contribution to the European Union funded Concerted Action "Improving efficiency and quality of health networks in urban areas" (ERB IC18-CT98-0338). The Swiss Agency for Development and Co-operation (SDC) and the Swiss National Science Foundation (SNSF) gave additional financial support for the study through the Dar es Salaam Urban Health Project (DUHP) and through the Individual Project 4 (IP4) of the NCCR North-South: Research Partnerships for Mitigating Syndromes of Global Change.

Conflicts of interest: none declared.

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Address to correspondence
Kaspar Wyss
email: kaspar.wyss@unibas.ch