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Table 3. Impact on quality, human resource and service utilization DD Kernel PSM (ATT) DD with kernel PSM (DD-PSM) Diff-in-diff Treated Control Difference Diff-in-diff Impact on the quality of care assessed at the health facility (score) Overall quality score (/68) 20.229*** 53.440 30.950 22.490*** 19.252*** Institutional quality (/12) 5.354*** 8.438 3.555 4.882*** 5.082*** Outpatient care (/11) 2.958*** 9.938 7.221 2.716*** 2.575*** Maternity (/12) 3.625*** 9.688 4.374 5.314*** 3.723*** Family planning (/8) 2.500*** 4.375 1.759 2.616** 2.509*** Vaccination and antenatal care (/7) 1.979** 5.313 3.352 1.961** 1.914** Laboratory (/5) 1.021* 4.688 3.769 0.921 0.688 Drug availability (/10) 1.792 8.188 5.136 3.052* 1.743 Supply availability (/3) 1.000** 2.813 1.784 1.029* 1.017* Impact on human resources in the health facility (number of staff per facility) Physicians 0.771 1.688 0.640 1.047 0.756 Nurses 1.896 5.063 2.105 2.957 1.926 Nurses’ aides 2.625 10.500 6.441 4.058 2.794 Unqualified staff 1.500 6.063 3.206 2.856 1.657 Impact health services utilization (coverage rates) Outpatient consultation -0.020 0.726 0.759 -0.033 -0.034 Under-one-year-old children vaccinated on time -0.036 0.803 0.833 -0.030 -0.036 Unwanted pregnancy 0.103 0.111 0.058 0.053 0.097 Modern contraceptive method 0.036 0.373 0.288 0.085* 0.036 Institutional delivery -0.011 0.981 1.000 -0.019 -0.004 Two or more antenatal care -0.021 0.953 0.968 -0.015 -0.011 Pregnant women antitetanic vaccination -0.022 0.867 0.877 -0.098 -0.025 Drug availability (/10) 1.792 8.188 5.136 3.052* 1.743 Source: PBF-LT surveys Note: *P
3 Institutions and structural quality of care in the Ghanaian health system Eugenia Amporfu, i Justice Nonvignon ii Corresponding author: Eugenia Amporfu, e-mail: eamporfu@gmail.com SUMMARY—Structural quality in the provision of health care refers to the availability of physical and human resources. The undersupply of such resources in health facilities leads to understaffing, outpatient and inpatient overcrowding and undersupply of tools needed for the provision of adequate health care. The provision of these resources is very much correlated with institutional factors, specifically governance and agent incentives. The aim of this study is to explore the effect of institutional factors on structural quality in public health facilities in the Ghanaian health system. New survey data on 62 public health facilities across three regions in Ghana were used. Principal component analysis was used to create three indices for structural quality: overcrowding, personnel and equipment. Three regressions were run for the quality indices on institutional factors. The results showed that regional hospitals were the most overcrowded and had the worst personnel shortages, but had the best performing equipment. Internal governance was found to be more important in reducing overcrowding than external governance. The opposite was the case for the equipment index. Personnel shortage was mild in facilities with opportunities for professional development. The study highlighted the importance of good coordination of facility administration with workers as well as with government in improving quality. Structural quality of health care refers to the availability of the physical and human resources required for the provision of care. 1 Measures of structural quality include health facilities’ physical equipment, and measures related to staff expertise and staff coordination and organization. 1 Even though this type of quality may not by itself ensure improved outcomes, 2 it is important because it focuses on the availability of all inputs necessary for the provision of care, without which better health outcomes may not exist. The definition of structural quality used in this study focused on the adequate supply and functional state of resources used for the provision of health care. Structural quality, then, ensures access to health care, which is necessary for the achievement of universal health coverage. Universal health coverage is achieved for a given economy when all residents, regardless of income, are able to have access to adequate health care without suffering financial hardship. 3 One of the important factors for achieving universal health coverage is access to technologies for the diagnoses and treatment of illness. The availability of these inputs for the provision of health care represents structural quality. Government intervention in the health-care market affects structural quality. In Ghana, for example, the government owns more than 50% all the health facilities in the country. 4 The government is responsible Voir page 69 pour le résumé en version française. Ver a página 69 para o sumário em versão portuguese. i Department of Economics, Kwame Nkrumah University of Science and Technology, Ghana ii School of Public Health, University of Ghana ISSUE 20 • SPECIAL ISSUE ON UNIVERSAL HEALTH COVERAGE 15
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separação de funções e a polít
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