Variability in Health Care Quality Measurement among Studies Using Service Provision Assessment Data from Low- and Middle-Income Countries: A Systematic Review

Am J Trop Med Hyg. 2020 Sep;103(3):986-992. doi: 10.4269/ajtmh.19-0644.


Quality of care is essential for improving health outcomes, but heterogeneity in theoretical frameworks and metrics can limit studies' generalizability and comparability. This research aimed to compare definitions of care quality across research articles that incorporate data from Service Provision Assessment (SPA) surveys. Following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we used a keyword search in PubMed. Each author reviewed abstracts, then full texts, for inclusion criteria, and peer-reviewed publications of empirical analysis using SPA data. The search yielded 3,250 unique abstracts, and 34 publications were included in the final analysis. We extracted details on the SPA dataset(s) used, theoretical framework applied, and how care quality was operationalized. The 34 included articles used SPA data from 14 surveys in nine countries (all in sub-Saharan Africa plus Haiti). One-third of these articles (n = 13) included no theoretical or conceptual framework for care quality. Among those articles referencing a framework, the most common was the Donabedian model (n = 7). Studies operationalized quality constructs in extremely different ways. Few articles included outcomes as a quality construct, and the operationalization of structure varied widely. A key asset of SPA surveys, owing to the standardized structure and use of harmonized data collection instruments, is the potential for cross-survey comparisons. However, this is limited by the lack of a common framework for measuring and reporting quality in the existing literature using SPA data. Service Provision Assessment surveys offer unique and valuable insights, and a common framework and approach would substantially strengthen the body of knowledge on quality of care in low-resource settings.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Systematic Review

MeSH terms

  • Analysis of Variance
  • Attitude of Health Personnel*
  • Delivery of Health Care / economics
  • Delivery of Health Care / organization & administration
  • Delivery of Health Care / statistics & numerical data*
  • Developing Countries / economics
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Income / statistics & numerical data
  • Quality of Health Care / economics
  • Quality of Health Care / organization & administration
  • Quality of Health Care / statistics & numerical data*
  • Research Design
  • Surveys and Questionnaires / statistics & numerical data