Rating Maternal and Neonatal Health Services in Developing Countries. (Research)

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Introduction

Experts in developing countries have rated family planning programme efforts (1-3), thus facilitating useful comparisons between countries (4) and allowing the effects of programme services on outputs to be analysed (5). Expert ratings for HIV/ AIDS programmes have also recently been introduced (6).

Such indicators of programme and service adequacy that are comparable across countries can be useful in identifying deficiencies, interpreting morbidity patterns and planning improvements. On the basis of judgements made by experts, we have obtained indicators for maternal and neonatal health services in 49 developing countries. The indicators, designed after a review of existing indicators for matemal health services (7-12), cover both routine and emergency care The present paper describes overall patterns across services and makes preliminary comparisons between countries.

Methods

The Futures Group International conducted the study in 1999 and early 2000, identifying individual consultants or consultant institutions for each of 49 developing countries and working with them to identify and recruit expert raters. Of the 10 to 25 raters selected in each country, at least two were from each of the following sources: the ministry of health (working in maternal and child health, hospitals, training, management information or elsewhere); private health care providers, including nongovernmental and community organizations; resident staff of international donors and related agencies; and medical schools and universities, associations of obstetricians and gynaecologists, nurses and midwives, and similar groups of knowledgeable observers.

Service providers comprised 42% of the 1037 raters; 61% of all the raters were physicians. The average country rater had eight years of experience at the national level and at least as much additional experience at the provincial, district or community level. There was no evidence of substantial systematic biases in ratings associated with the training or experience of raters (13).

The experts were asked to rate services on an 81-item questionnaire, the Maternal and Neonatal Programme Effort Index. The items in the questionnaire covered antenatal care, treatment for complications of delivery, neonatal care, immunization, the control of sexually transmitted infections, and many other areas. The items were grouped not by medical condition but with reference to different stages involved in organizing and delivering care, from setting policy to attending to patients (Fig. 1). Also included, although not represented in the diagram, was the provision of family planning, the one substantive area separately covered. Taken together the elements represented programme effort as distinct from health outcomes.

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The experts rated services from 0 to 5. For example, in relation to the statement "All pregnant women have their labour monitored", a rating of 5 indicated that this was completely true whereas a rating of 0 indicated this was completely false. The ratings were multiplied by 20 to give a range of 0 to 100. A slightly different scale was employed for the assessment of access to services, indicating the percentage of pregnant women with adequate access to each service. Thus a range of 0 to 100 was again used. The experts were expected to give their own opinions but were free to consult with colleagues or refer to available health system or household survey data.

Of the 49 countries, 23 were in Africa, 13 were in the Americas and 13 were in Asia (Table 6). They included the largest developing countries as well as countries of special policy interest, comprising 84% of the population of the developing regions. Partly because of its size, India was treated in more detail than the other countries: programmes were rated separately for each of 14 states containing some 85% of the national population. …