The Business of Quality: Evaluating the Impact of Healthcare Quality Improvements on Staff Numbers and Patient Utilization in Sub-Saharan Africa

Every year an estimated 5 to 8 million people die in low- and middle-income countries (LMICs) due to poor-quality care. Although quality improvements in healthcare facilities in LMICs are well-possible with tailored implementation plans, costs are often mentioned as a prohibiting factor. However, if quality improvements increase trust among patients, this might translate into increased visits and higher revenues for providers and enable them to further invest in quality. This paper assesses the potential business case of quality improvements in Sub-Saharan Africa (SSA). It focuses on both the public and private sector since the latter provides at least half of all health services in SSA. The analysis is based on a dataset including multiple assessments of quality and business performance indicators for almost 500 health facilities in Tanzania, Kenya, Ghana, Nigeria, and other SSA-countries. We studied the association between changes in quality assessment scores and subsequent changes in numbers of patient visits and staff as proxies for business growth. We found that quality improvements significantly improved business performance indicators, but only for those facilities that had already reached a certain level of quality to begin with. These findings suggest an S-shaped relationship between quality and business performance, leading to the existence of a low-quality trap. Substantial financial investments might be needed initially to support facilities at the bottom of the distribution in reaching a basic level of quality, after which further quality investments may start translating into increased revenues, enhancing business performance. Key messagesO_LIMillions of people die every year in low- and middle-income countries (LMICs) due to low quality of care C_LIO_LITo reach Universal Health Coverage, drastic quality improvements are essential C_LIO_LIAchieving quality of care in LMICs is possible but challenging because it requires substantial financial investments, specialized skills and sufficient human resources C_LIO_LIWe found there is a business case for quality investments in SSA, as quality improvements are associated with a significant increase in the number of patient visits and staff over time, indicative of greater revenue streams and financial capacity C_LIO_LITargeted financing programmes together with technical assistance to healthcare facilities are critical to drive quality investments, especially for facilities at the beginning of their quality improvement journeys C_LI