The business of quality: analysing the association between healthcare quality improvements and patient utilization and staff numbers in sub-Saharan Africa.

BACKGROUND: An estimated 5 to 8 million people die each year in low- and middle-income countries due to poor-quality care. Although quality improvements in healthcare facilities are feasible, costs are often mentioned as a prohibiting factor. However, if quality improvements increase patient trust and demand, this might translate into increased visits and higher revenues for providers, enabling further investments in quality. This study assesses the potential business case of quality improvement in sub-Saharan Africa. METHODS: We analysed quality assessment scores and business performance indicators of 483 public and private facilities in Tanzania, Kenya, Ghana, and Nigeria. Using longitudinal data collected at least 18 months apart, we examined associations between changes in quality scores and changes in patient visits and staff levels, as proxies for business performance, based on linear regression analyses of baseline and follow-up data. RESULTS: Quality improvements were significantly associated with increased patient visits [β=10.1, 95% confidence interval (CI): 3.6‒16.6]. Facilities with higher baseline quality scores experienced larger increases in patient visits, as did those who started with lower baseline patient volumes. Longer follow-up periods were also associated with larger increases. Similarly, quality improvements were associated with increases in staff numbers (β=0.25, 95% CI: 0.13‒0.38); again, facilities with higher quality scores and lower staff numbers at baseline experienced larger increases. CONCLUSIONS: Quality improvements are positively associated with our business performance proxies, patient visits and staff numbers, suggesting a potential business case for QI in these facilities, although causality cannot be established. Findings suggest that time is needed for this association to materialize. Targeted initial investments might be needed to support lower-performing facilities in realizing business performance gains similar to those of facilities with higher quality scores, particularly where resources or capacity are limited. Public-private partnerships, along with innovative loan schemes, could help bridge these gaps.