Evaluating the Effectiveness of Quality Improvement Strategies in Mid-Level Private Healthcare Facilities of Lagos State: A Donabedian Model-Based Approach

The process domain evaluates the actions and activities that occur within healthcare delivery ⁹. It focuses on adherence to standards, clinical protocols, and patient care practices ⁹. Quality processes involve the delivery of care, encompassing diagnostics, treatments, and the overall patient experience ⁹. In the context of Lagos State's mid-level private healthcare facilities, assessing healthcare processes is pivotal ¹⁴. It enables the identification of areas that require improvement and provides insights into how the application of quality improvement strategies can enhance healthcare practices ¹⁴.

The outcomes domain evaluates the effects of healthcare interventions on patients' health and satisfaction ¹⁰. It provides a holistic perspective on care quality, as it considers the results of healthcare delivery ¹⁰. Outcomes may encompass patient health improvements, prevention of complications, and enhanced patient satisfaction ¹⁰. For the research in Lagos State, evaluating outcomes is fundamental to comprehensively assess the impact of quality improvement interventions ¹⁴. It allows for the measurement of healthcare effectiveness, patient well-being, and the overall quality of care provided by mid-level private healthcare facilities ¹⁴.

Quality improvement strategies often begin with assessing and enhancing the structural elements within healthcare facilities ⁴⁴. In Lagos State, this may involve interventions aimed at improving the infrastructure, ensuring an adequate supply of resources, and investing in healthcare personnel training and development ¹⁴. By applying the structural component of the Donabedian Model, the research can assess whether such interventions have indeed enhanced the readiness of these facilities for quality improvement ¹⁴.

Quality improvement initiatives frequently target process improvement ³³. In the context of Lagos State's mid-level private healthcare facilities, this may include interventions to enhance the adherence to clinical protocols and patient care practices ¹⁴. Using the process component of the Donabedian Model, the study can determine the impact of these interventions and identify areas where healthcare processes have improved ¹⁴.

Quality improvement is ultimately aimed at producing positive healthcare outcomes ⁶. In Lagos State, assessing the impact of quality improvement strategies on healthcare outcomes, patient satisfaction, and the overall quality of care is vital ¹⁴. The outcomes component of the Donabedian Model will facilitate the comprehensive evaluation of these effects ¹⁴.

The Donabedian Model, with its three core domains of structure, process, and outcomes, provides a comprehensive framework for assessing healthcare quality ¹⁰. This model has been instrumental in guiding quality improvement strategies in healthcare ¹³. For the research in Lagos State, it serves as a foundational framework to comprehensively assess the effectiveness of quality improvement strategies in mid-level private healthcare facilities. By evaluating structural components, healthcare processes, and healthcare outcomes using this framework, the research aims to contribute to the enhancement of healthcare quality in Lagos State and promote quality healthcare in the pursuit of Universal Health Coverage (UHC).

This aspect includes the physical assets of healthcare facilities, such as hospital buildings, clinics, medical equipment (e.g., diagnostic tools, surgical instruments), and technologies (e.g., electronic health records) ¹¹. Adequate infrastructure is fundamental to the effective provision of healthcare services, ensuring a safe and conducive environment for patient care.

The availability and adequacy of resources, both human and material, are fundamental structural elements ¹¹. Human resources involve the qualifications, competencies, and skill sets of healthcare personnel, such as physicians, nurses, allied health professionals, and support staff. Material resources include the availability of essential supplies, medications, and medical consumables. The presence of skilled healthcare professionals and necessary resources is pivotal for the seamless delivery of quality care.

The study population consisted of mid-level private healthcare facilities operating in Lagos State. The research focused on randomly selected health facilities that met specific selection criteria. These facilities were chosen from 15 Local Government Areas (LGAs) within the state, including Alimosho, Agege, Ajeromi/Ifelodun, Amuwo-Odofin, Apapa, Ifako Ijaye, Ikeja, Kosofe, Lagos Island, Lagos Mainland, Mushin, Ojo, Oshodi/Isolo, Somolu, and Surulere.

Data collection commenced with a baseline assessment, which included 321 selected mid-level private healthcare facilities across Lagos State. This assessment aimed to understand the status of service quality across the clinical and administrative processes of these facilities. Data was collected using a consolidated facility quality assessment tool, which incorporated Health Facility Monitoring and Accreditation Agency (HEFAMAA) monitoring standards, healthcare quality standards (WHO’s Service Availability and Readiness Assessment – SARA and InSiGHt’s Quality Estimation Tool– QuEst), and Lagos State Health Management Agency (LASHMA) empanelment criteria. The tool was administered to Medical Directors (MDs) and facility managers. The assessment covered various aspects, including management and administrative systems, available services, medical equipment, waste management, infection control, financial management, patient care management, quality improvement, maternal, neonatal, and childcare, family planning, and data management. Additionally, one client exit interview was conducted in each of the 321 selected facilities with randomly selected clients.

Subsequently, the study implemented quality improvement interventions in the selected facilities over a period of 10 - 12 months, strategically employing the PDSA (Plan-Do-Study-Act) model. This comprehensive approach included the development and distribution of facility-specific quality improvement plans, debriefing facilities on findings and the details of the plan, and the constitution of quality improvement systems. These systems comprised dedicated quality improvement teams or champions. Additionally, the study provided relevant guidelines, Standard Operating Procedures (SOPs), charts, job aids, and reporting templates to facilitate the effective implementation of the plans. The intervention strategy also encompassed conducting physical support and monitoring visits, along with offering virtual support to facilities. To enhance the capabilities of healthcare providers and facility staff, the study conducted targeted training and other capacity-building activities. This multifaceted approach, grounded in the PDSA model, aimed to optimize the impact and sustainability of the Quality Improvement Plans (QIPs).

Following the 12-month quality improvement intervention period, the research conducted an endline assessment. The endline assessment involved data collection at -239 health facilities (the health facilities that sustained participation in the research throughout the intervention period) to evaluate the effects and contributions of the intervention on service provision and accessibility. The quantitative component consisted of facility assessment using the consolidated facility quality assessment tool and client exit interviews, while the qualitative component involved interviews with key stakeholders, including LASHMA, HEFAMAA, and Medical Directors/ facility managers of selected facilities.

This area evaluates the effectiveness of the administrative structure, encompassing elements such as the organogram, board of directors, administrative SOPs, guidelines, workplan, staff recruitment process, staff health insurance, and environmental conditions, including the provision of basic hospital amenities.

Focused on the provision of basic health and MNCH services, this area assesses the availability and quality of emergency care, Antenatal Care (ANC), Family Planning (FP), Prevention of Mother-to-Child Transmission (PMTCT) pharmaceuticals, and laboratory services.

Evaluation in this area centers on the facility's readiness for emergencies, including the availability of emergency transportation, well-documented referral forms, and effective patient follow-up services.

This area scrutinizes the facility's patient care procedures, emphasizing the availability of documented clinical procedures, guidelines, job aids, essential medical equipment (basic, general, and surgical), and respiratory treatment supplies.

Focused on the cleanliness, safety, and infection control measures within clinical rooms, including treatment rooms, delivery rooms, consulting rooms, and laboratories.

Evaluation here centers on the availability of infection control processes, encompassing handwashing facilities, proper management of sharps, sterilization processes, and the use of Personal Protective Equipment (PPE).

This area assesses the facility's waste management processes, including the availability of color-coded waste bins, proper waste disposal, and adherence to guidelines for waste management.

Focused on the facility's information management, this area evaluates the availability and proper usage of Health Management Information System (HMIS) registers/forms, regular submission of HMIS forms, and the availability of a medical record storage system.

A comprehensive evaluation covering the availability and quality of maternal care, ANC, newborn and childcare services, use of partograph during delivery, availability and use of Antenatal Record and Follow-up (ARAF) during ANC, availability of FP services with trained and dedicated staff, availability of FP commodity utilization record, and the availability of a diverse FP methods mix.

Focused on the facility's financial processes, including the

availability of a functional accounting system, appropriate accounting tools, adherence to fiscal policies and procedures, and accessibility to funding.

Evaluates the facility's commitment to quality improvement, including the allocation of resources, supporting policies that drive quality improvement, availability of a functional Quality Improvement (QI) team/champion, SOPs for QI/QA, data and information availability for decision-making, and the presence of a feedback mechanism.

This area assesses the facility's registration status with relevant regulatory bodies, including HEFAMAA, Corporate Affairs Commission (CAC), and Public Procurement Agency (PPA).

Patient Satisfaction (Client exit interview) (14 points): Evaluation in this area is centered on patients' perceptions of the facility's service delivery, including cleanliness, friendliness, courteousness, skills and abilities of healthcare providers, communication style, and waiting time.

The total maximum score achievable across all priority areas is 402, providing a comprehensive benchmark for assessing the overall quality of MNCH/FP services in the healthcare facilities under consideration.

The sample size was determined by the targeted number of mid-level private providers that participated in the Private Providers Readiness Project – a workstream of the Strategic Purchasing for Family Planning (SP4FP) project.For the baseline assessment, 321 mid-level private healthcare providers were selected, covering all facilities enrolled in the project. The selection of this number was predetermined and agreed upon by project coordinators in consultation with HSCL and LASHMA, based on projected target empanelled facilities and available resources. At the endline assessment, 239 health facilities were assessed, taking into consideration those that completed the project cycle. For client exit interviews, 321 respondents were interviewed at the baseline (one client per facility), while 239 respondents were interviewed at the endline. In the endline qualitative component, 20 Medical Directors or facility managers were interviewed, along with one representative each from the project stakeholders (LASHMA, HEFAMAA, and HSCL)

The data collection process utilized the following tools: consolidated facility quality assessment tool for health facilities assessment., and the interview guides for providers, partners, and key informant interviews.

Prior to the baseline data collection period, a three-day training session was conducted for enumerators and supervisors. Training covered orientation on the research protocol, assessment tools, and safety and security mitigation protocols. A one-day pre-test of all data collection tools followed immediately after enumerator training. Data collectors underwent a refresher training session before the endline data collection. Pre-testing and refresher training were aimed at ensuring data collection tools' clarity, functionality, and the quality of data collected.

Baseline data collection was collected to inform the scope of intervention in each facility. Endline data collection was conducted by a team consisting of twelve members. Four members of the research team conducted key informant interviews, while an additional eight data collectors were sourced from a pool of data collectors within the state, complemented with HEFAMAA monitors for facility assessments. For key informant interviews, the four interviewers were divided into two pairs, with each pair conducting two key informant interviews per day. The data collection process was planned to be completed in twelve days, following a specific schedule.

This research employed both paper-based and electronic data collection methods. Quantitative data collection utilized the KoboCollect platform on mobile devices for ease of collection, storage, retrieval, and analysis. Health facilities assessments and client exit interviews were administered using electronic questionnaires. Qualitative data collection involved paper-based interview guides for selected respondents. Key informant interviews were audio-recorded (with participants' consent), while notes were taken for respondents who did not consent to recording. The audio recordings were uploaded daily for quality assurance and transcription.

Data collected were synchronized at the end of each data collection day, allowing for daily data validity checks and quality assurance. All mobile devices came with pre-loaded SIM cards with mobile data. Additional devices were available to circumvent issues related to device damage. Spot checks were conducted on a daily basis to verify adherence to the data collection process. During client exit interviews, consistency checks, and validation checks were programmed into the KoboCollect platform, which could not be bypassed. If incorrect data were entered, the system triggered an error message, which could only be rectified by returning to the correct page for entry. Additionally, supervisors oversaw data collection and regularly reviewed the data for accuracy. Validation was performed by confirming the accuracy of data recorded with participants at the point of data collection.

Data from the quantitative surveys were entered into the KoboCollect platform and subsequently exported to statistical software for analysis. Qualitative data from interviews were transcribed and reviewed for clarity and accuracy.

Descriptive statistics, such as frequencies, proportions, and means, will be used to summarize data. The data was analyzed using SPSS 25.0.

Thematic analysis was applied to the qualitative data, allowing for the identification of key themes and patterns emerging from the interviews. These themes were used to inform qualitative data interpretation.

This research project adheres to ethical principles, and all research activities are conducted in accordance with the ethical guidelines and principles of research. Approval was secured from the Research Ethics Committee of the State Ministry of Health. Written informed consent was obtained from all study participants, ensuring their right to withdraw from the research at any time without negative consequences. Confidentiality and privacy were assured, and participants were assigned unique identification numbers to protect their identities.

The dataset reveals notable shifts in the staffing composition of healthcare facilities between the baseline (2021/2022) and endline (2022/2023) periods, accompanied by percentage changes. In terms of doctors, there is a slight decrease from 206 to 198, constituting an 8 (-4%) reduction. Conversely, the count of nurses/midwives has increased from 151 to 178, marking a 27 (18%) rise. However, a significant decline is observed in the overall nurse category, dropping from 444 to 256, signaling a substantial change of -188 (-42%). Pharmacists have experienced a considerable reduction, decreasing from 40 to 20, accounting for a 20 (-50%) change. Lab scientists show growth, increasing from 58 to 70, reflecting a 12 (21%) change. Records officers have seen an increase from 59 to 68, representing a change of 9 (15%). In contrast, financial officers and admin staff exhibit marginal decreases of -1 (-3%) and -3 (-4%), respectively. These nuanced variations necessitate a careful consideration of their implications on healthcare service delivery and underscore the dynamic nature of staffing in these facilities. Continued attention to optimizing staffing for enhanced service quality is essential. Numerous pieces of research have consistently highlighted that staffing levels play a critical role in shaping patient outcomes and satisfaction levels. Inadequate numbers of healthcare professionals can have a detrimental impact on healthcare access and compromise the overall quality of services. The reduced count of nurses and midwives in particular were a challenge for facilities in meeting empanelment requirements. It also points to turnover of trained staff which could explain the impact in areas such as infection prevention and reduced family planning services. It signals a concerted effort to address the long-standing issue of staff shortages, ultimately bolstering the readiness of these healthcare facilities to provide high-quality care. This workforce challenge impacts the facility's ability to meet the healthcare needs of the community but also holds the potential to improve the overall health outcomes and satisfaction of patients, thereby contributing to the broader goal of healthcare quality enhancement.

The facilities consistently maintained high compliance with essential equipment throughout the study period, which aligns with findings from previous research ²⁸ emphasizing the pivotal role of proper equipment in healthcare delivery. The availability and functionality of essential equipment are paramount for accurate diagnosis and effective treatment, directly influencing the quality of care provided. The significant compliance levels observed at both the baseline and endline of the study are in line with existing literature that underscores the critical importance of equipping healthcare facilities with the necessary tools and instruments to ensure the delivery of high-quality healthcare services. Properly functioning equipment not only enhances the efficiency of healthcare providers but also contributes to improved patient outcomes. The minimal change in compliance indicators for essential equipment further suggests that the facilities effectively maintained and managed their equipment throughout the study period ²⁸.

The study revealed a noteworthy increase in the availability of protocols for priority disease conditions, rising from 32.5% at the baseline to 46% at the endline. This finding strongly resonates with previous research, as exemplified by studies like ²⁶, which underscore the critical importance of standardized protocols in healthcare settings. Adherence to SOPs plays a pivotal role in ensuring evidence-based practice, reducing unwarranted variations in care, and ultimately enhancing the overall quality of healthcare services. The observed increase in the availability of protocols aligns seamlessly with the existing literature, which highlights the significance of standardized protocols for delivering care that is both consistent and evidence-based. Research has consistently demonstrated that adherence to clinical guidelines and standardized protocols is associated with improved quality of care and enhanced patient outcomes. Therefore, the substantial increase from 32.5% to 46% in the availability of these protocols within the studied healthcare facilities signifies a positive stride toward the delivery of higher-quality care ²⁶.

The analysis revealed significant enhancements in facility infrastructure, particularly in the areas of ventilation, electricity, and water supply. This transformation is in line with existing research, exemplified by the work of ³, which underscores the pivotal role of quality facility infrastructure in shaping the patient experience and effectively managing infection control. Adequate ventilation and a reliable, clean water supply are not just amenities; they are fundamental prerequisites for maintaining a safe and conducive healthcare environment. These improvements suggest a commendable effort by healthcare facilities to create a more favorable and secure setting for both patients and healthcare providers. The findings align with literature emphasizing the importance of infrastructure improvements in healthcare settings for enhancing patient satisfaction and ensuring infection control measures are me

The data shows encouraging progress in terms of healthcare facility registration and compliance with regulatory requirements. The percentage of facilities registered with the Corporate Affairs Commission (CAC) has grown from 89.8% to 97.5%, indicating that more facilities have obtained official registration. Moreover, registration status with HEFAMAA (Lagos State Health Facility Monitoring and Accreditation Agency) improved from 94.4% to 97.5%. A noteworthy development is the substantial increase in facility license renewal status with HEFAMAA, surging from 41.4% to 95.4%. This reflects a substantial boost in the number of facilities actively renewing their licenses, which is a significant step toward ensuring regulatory compliance. These changes closely align with the existing literature, which consistently underscores the importance of healthcare facilities operating within the legal framework and adhering to regulatory requirements. Proper registration and compliance not only demonstrate commitment to legal standards but also play a pivotal role in building patient trust and elevating the overall quality of services provided. The improvement in these aspects is a positive sign, as it indicates that healthcare facilities in Lagos State are taking the necessary steps to operate within established legal and regulatory guidelines.

The expansion in the availability of clinical rooms, including consulting, delivery, and treatment rooms, is vital for the effective delivery of healthcare services. Existing literature underscores the significance of well-equipped clinical spaces to ensure the provision of diverse healthcare services efficiently (Smith et al., 2016). This improvement in infrastructure suggests a positive stride toward enhancing the overall healthcare environment and capacity to offer a wide range of services.

The analysis yielded mixed results in service availability, with some services showing improvements (e.g., antenatal care and postnatal care) while others experienced declines (e.g., family planning). Research has underscored the significance of comprehensive healthcare services, especially in areas related to maternal and child health ²¹. Disparities in service availability can have a notable impact on community health outcomes. The fluctuating trends observed in service availability may be attributable to workforce shortages and turn over experienced by the facilities. Nurses are typically the providers of family planning services ³, ⁴². While improvements in antenatal care and postnatal care services are promising, the decrease in family planning services is a cause for concern. The literature emphasizes the need for healthcare facilities to offer a comprehensive range of services to address the diverse healthcare needs of the population. The decline in family planning services, may also necessitate special attention to increasing the availability of family planning commodities, particularly LARCs, outside of the government supply system, as family planning plays a crucial role in maternal and child health.

The latest data reveals significant improvements in certain aspects of referral capacity and emergency response within the healthcare facilities. Specifically, the percentage of facilities with an established referral system increased from 78% to 91.1%, demonstrating a positive trend towards ensuring the continuity of care ³⁴. This enhancement in the referral system aligns with established literature emphasizing the pivotal role of a well-structured referral process in healthcare systems. Emergency transportation arrangements also saw positive progress, with a notable increase from 71.4% to 86.8%. This improvement is crucial for timely and effective responses to emergencies, ultimately contributing to the reduction of morbidity and mortality rates ²⁰. Additionally, there were positive trends in the availability of referral forms (92.5%) and the practice of patient follow-up (94.1%), both of which are indicative of a comprehensive approach to emergency response and patient care. The data underscores the commitment of the healthcare facilities to strengthen their emergency response capabilities, aligning with global health priorities. These improvements contribute to the overall preparedness of the facilities to handle medical emergencies, ultimately enhancing the quality of care provided to patients. Continuous attention to these aspects will be crucial in sustaining and further advancing the emergency response mechanisms within the healthcare facilities.

The analysis of sterilization and infection control indicators revealed a mixture of results, with improvements in some areas and a concerning decline in handwashing facilities equipped with cleansing agents and water. Adequate infection control practices, especially proper hand hygiene, are critical for preventing healthcare-associated infections ³¹. Continuous monitoring and improvement in these practices are essential to maintain a safe healthcare environment. The observed improvements in some sterilization and infection control indicators align with the existing literature, which consistently emphasizes the significance of stringent infection control practices within healthcare facilities. However, the decline in the availability of handwashing facilities equipped with cleansing agents and water raises a significant concern, especially considering its potential connection to nursing shortages. Hand hygiene being fundamental in the prevention of healthcare-associated infections is intricately linked to the availability and functionality of handwashing facilities. Nursing shortages have been associated with compromised infection control measures in healthcare settings ³⁶. The intricate nature of healthcare operations requires an adequate workforce to maintain optimal infection control standards. A shortage in nursing staff could potentially strain the seamless implementation of hand hygiene protocols, contributing to the observed decline in this crucial aspect. To address this concern effectively, further investigation into the specific challenges faced by nursing staff in adhering to infection control protocols is warranted. Strategies for mitigating nursing shortages and enhancing infection control education and resources should be explored to fortify the overall safety of healthcare environments. This integrated approach aligns with the overarching goal of maintaining a robust infection control framework and upholding patient and staff well-being.

The evaluation of waste management practices revealed high compliance with waste management regulations and a noteworthy increase in the availability of color-coded waste segregation bags. Proper waste management is crucial in healthcare settings for infection prevention and maintaining a safe environment ⁴⁵. Compliance with waste segregation guidelines plays a pivotal role in reducing the risk of contamination and enhancing overall safety. The high level of compliance with waste management regulations and facilities' registration with LAWMA, coupled with the improved availability of color-coded waste segregation bags, aligns with the guidance provided by existing literature. Numerous studies underscore the significance of effective waste management in healthcare settings for infection control and ensuring the safety of both patients and healthcare professionals.

The overall average QI score, calculated based on priority areas, reflects the comprehensive impact of the quality improvement intervention.

Table 3 shows the average QI score for individual health facilities, and this provides insights into the varied impact of interventions on different providers. The baseline average QI score of 69% suggests a baseline level of quality across facilities. The increase to an endline average QI score of 74% indicates an overall improvement, showing that the majority of facilities experienced positive changes. This finding emphasizes the need for tailoring interventions to address specific challenges faced by individual facilities, acknowledging the diverse contexts and operational nuances that influence the impact of quality improvement initiatives. Figure 1, shows the number of healthcare facilities with their respective quality improvement score average at the baseline and endline.

Figure 1.Healthcare Facilities with QI Scoring

Table 3 details how the quality improvement scores was computed, and Table 4 shows that the priority areas and quality improvement score across the healthcare facilities accessed.

The Management and Administrative System, assessed against structured administrative processes and amenities, maintained a consistent score of 63%. This indicates stability in the organizational structure. Availability of basic health and MNCH services improved from 76% to 80%, showcasing enhancements in service provision.

A notable progress is observed in Referral Capacity and Emergency Response, with the score increasing from 72% to 91%. This improvement indicates a more robust system for emergency transportation, referral forms, and proper documentation, achieving 91% of the maximum obtainable score of 8.

Patient Care Management slightly improved from 83% to 85%, suggesting better adherence to documented clinical procedures and the availability of essential medical equipment.

Adequacy Of Clinical Rooms saw a modest improvement from 85% to 87%, indicating better cleanliness, safety, and infection control measures in clinical areas.

Standard Precautions for Prevention of Infections experienced a decline from 89% to 80%, possibly indicating challenges in maintaining infection control processes, including handwashing facilities and the use of PPE.

Waste Management remained consistently high, with a slight increase from 91% to 92%, indicating effective waste management processes.

Positive change is noted in the Health Management Information System, with the score increasing from 64% to 67%. This suggests improved usage of relevant HMIS registers/forms.

Significant improvement is observed in Maternal, Neonatal, and Child Health Care / Family Planning Services and Utilization, with scores increasing from 52% to 62%.

Positive progress is seen in the Financial Management System, with the score increasing from 50% to 59%. This indicates improvements in the accounting system, fiscal policies, and funding accessibility.

Quality Assurance and Quality Improvement show positive growth, moving from 68% to 77%, indicating enhanced commitment to quality improvement, resource allocation, and supporting policies.

There is substantial improvement in Registration and Administration, with scores increasing from 70% to 84%, indicating progress in meeting registration requirements with relevant authorities.

Patient satisfaction experiences a remarkable improvement from 11% to 83%, reflecting a significant enhancement in patients' perception of the facility’s service delivery.

The overall Average Quality Improvement Score demonstrates positive progress, increasing from 69% to 74%, indicating an overall improvement in the quality of MNCH/FP services across the assessed priority areas.

The observed changes in the number of staff across various categories have profound implications for both health workforce dynamics and overall infrastructure in the examined healthcare facilities.

The slight decrease in the number of doctors (-4%) may impact the overall capacity for clinical consultation and decision-making. Efforts should be directed toward retaining and attracting qualified medical professionals to maintain high-quality patient care. The notable increase in nurses and midwives (18%) is a positive sign, potentially enhancing the provision of patient care, especially in areas like maternal and child health. This increase is encouraging for meeting the diverse healthcare needs of the community. The significant reduction in the overall number of nurses (-42%) raises concerns about potential challenges in maintaining adequate nursing care. This decline necessitates a focused strategy for recruitment and retention to address the impact on healthcare services. Pharmacists, Lab Scientists, Records Officers, Financial Officers, Admin Staff; the fluctuations in these categories suggest a dynamic work environment. While certain roles have experienced reductions, attention should be paid to ensure that essential functions like pharmacy services, laboratory support, record-keeping, and administrative tasks are not compromised.

The changes in staffing levels emphasize the need for a flexible and adaptive infrastructure. Facilities must be equipped to accommodate fluctuations in personnel to ensure operational continuity. The increase in nurses and midwives may necessitate adjustments in patient care facilities to accommodate the growing workforce, emphasizing the importance of having adequate clinical rooms, equipment, and resources. The changes underscore the need for continuous training and development programs to equip the healthcare workforce with the necessary skills to navigate shifts in staffing and maintain service quality. The reduction in certain administrative staff positions may impact financial and administrative functions. Facilities should evaluate their financial management systems to ensure efficiency in the face of staffing changes.

The increase in adherence to Standard Operating Procedures (SOPs) and protocols for priority disease conditions is a positive trend. Standardized protocols play a crucial role in ensuring evidence-based practice, reducing variations in care, and enhancing the overall quality of healthcare services. The improvements in compliance with waste management regulations are commendable, contributing to infection prevention and overall safety.

Continued emphasis on adherence to SOPs, guidelines, and waste management protocols is essential. Regular training and monitoring can further enhance compliance, ensuring consistent high-quality care.

While there were improvements in services like antenatal care, postnatal care, and certain contraceptive methods, the decline in family planning, child health services and laboratory service availability are concerning. Comprehensive healthcare services, especially in maternal and child health, are vital. Understanding the reasons behind the decline in certain services is crucial for addressing gaps.

Addressing the decline in family planning services requires targeted interventions, potentially including commodity security, task shifting to address nursing shortages, and staff training. Investigating the reasons behind reduced laboratory services is essential for ensuring timely and accurate diagnostics.

The improvement in average quality improvement scores from 69% to 74% indicates an overall positive impact of quality improvement interventions. However, the presence of facilities with decreased scores suggests variations in the effectiveness of these interventions.

Tailoring interventions to individual facility need and consistently monitoring the impact of quality improvement initiatives are crucial. Identifying and addressing challenges faced by facilities with decreased scores will be instrumental in sustaining positive changes across all healthcare providers.