This study examined the impact of accreditation on health care performance at three health facility categories in Kiryandongo district, Uganda.
Accreditation positively impacted the selected indicators; new clients on ART, TB case diagnosis, TB case enrolment, malaria case diagnosis, laboratory sample referral, maternity admissions, maternity deliveries, immunisations and reporting to dhis-2 for hmis 105:10.
Accreditation did not however impact the indicators for; days out of stock for ART medication (TDF/3TC/DTG, ABC/3TC) and Hepatitis B Testing.
HIV services performance
The accredited facility was more likely to enrol new HIV patients on ART (OR = 1.14) in comparison to the non-accredited public facility and (OR = 1.26) in comparison to the non-accredited PNFP. Furthermore, the accredited facility was less likely to experience stockouts for HIV testing kits (OR = 0.91- Determine, OR = 0.87-StatPak) in comparison to the non-accredited public facility. The difference in new enrolments for HIV and days out of stock for HIV testing kits at the accredited facility were statistically significant, P < 0.05. The accredited facility however had higher stockouts for antiretroviral medication (OR = 1.05-TDF/3TC/DTG, OR = 1.07- ABC/3TC). The difference in stockout of antiretroviral medication at the accredited facility was however not statistically significant, P > 0.05.
The HIV performance at the accredited facility can be explained by the increased community awareness of the facility’s accreditation status and improved stock management of the HIV testing supplies by the laboratory and the facility. This may have resulted into an increased utilization of the HIV services at the facility. These results are similar to those obtained by Ebong et al., in Cameroon who reported customer satisfaction of up to 64% for the adult volunteers attending HIV Infection Testing and Service Delivery at an accredited treatment Centre [22]. A similar study by Billong et al., in Cameroon, reported an increase in HIV testing performance (sensitivity by 10.2% and specificity by 0.3%) following implementation of quality systems interventions in PMTCT programs [23].
TB services performance
The accredited facility was more likely to identify, diagnose and enrol TB cases (OR = 1.06, 1.28, 1.19 respectively) compared to the non-accredited public facilities. Similarly, the accredited facility was more likely to identify, diagnose and enrol TB cases (OR = 1.47, 1.33, 1.24 respectively) compared to the non-accredited PNFP facilities. The difference in TB case diagnosis and enrolments at the accredited facility were statistically significant, P < 0.05. Further on, the accredited facility had lower stockouts for GeneXpert cartridges (OR = 0.78) compared to the non-accredited public facilities. The difference in days out of stock for TB GeneXpert cartridges at the accredited facility was statistically significant, P < 0.05.
The TB services performance at the accredited facility may be explained by the improved stock management, reduced reagent wastage and reduced service interruptions. In addition, the implementation of the National TB program activities such as support supervision by the district health teams, weekly reporting, blinded rechecking and GeneXpert external quality assurance within Kiryandongo district may also have contributed to this performance [24]. The National TB program activities aim at strengthening the implementation of TB activities in Kiryandongo district and the country at large.
Our findings are similar to those by Getahun et al., in Ethiopia who reported establishment of an effective inventory management system that enabled laboratory supplies forecast, reduced reagent wastage and service interruptions to tuberculosis direct sputum smear microscopy services. A similar study by Susanne Homolka et al., in Germany reported an increase in odds ratio by 108% for a sample to be tested as microscopically positive following implementation of Quality Management Systems [25, 26]. Furthermore, a study by Brugueras et al. in Spain reported significant differences in TB treatment and management for sample collection, documentation of final results, management of resistance, coordination with other departments, contact tracing and directly observed treatment for accredited TB units when compared to the non-accredited units [27].
Malaria services performance
The accredited facility identified and diagnosed less malaria cases (OR = 0.62, 0.46 respectively) compared to the non-accredited public facilities. The accredited facility however identified and diagnosed more malaria cases than the non-accredited PNFP facility (OR = 2.16, 2.07 respectively). The difference in malaria identification and diagnosis at the accredited facility was statistically significant, P < 0.05.
The findings for malaria performance at the non-accredited public facilities are in tandem with the role played by the HCIIIs as the first level referral cover for laboratory testing in the district. This is aimed at preventing decongestion at the higher levels of health care by the common conditions in the district. The findings at the non-accredited PNFPs may also be explained by the nominal fees being charged for malaria testing whereas in the public facilities, testing is paid for by the MoH hence free to the public.
The Malaria performance findings emphasize the need to implement quality management systems at the lower health facilities that constitute a large bulk of malaria treatment. Our findings are in tandem with those obtained by Thomson et al., in Tanzania [28] and Dorkenoo et al., who showed that the implementation of quality management systems, refresher training and expanded PT at remote testing facilities are essential for improving the quality of malaria diagnosis [29].
Laboratory services performance
The accredited facility was also more likely to receive referral samples (OR = 1.67) as compared to the non-accredited public and PNFP facilities. The difference in sample referral to the accredited facility was statistically significant, P < 0.05. This finding may be explained by the designation of the accredited facility as a hub for the district by MoH. The facilities within the district are mandated to refer samples for viral load testing, early infant diagnosis among other tests to the National Reference Laboratories through the hub system [30].
Further on, the accredited facility was more likely to conduct Hepatitis B testing compared to the non-accredited public and PNFP facilities (OR = 1.04, 1.24 respectively). The difference in Hepatitis B testing at the accredited facility was however not statistically significant, p > 0.05. This finding may be due to the implementation of the National Hepatitis B activities such as free testing, mass vaccination campaigns conducted at the different health facilities in the district. These activities are in line with MoH’s agenda of advancing the fight against Hepatitis B disease [31].
Maternal and child health services
The accredited facility was more likely to register maternity admissions, maternity deliveries, BCG immunisations and pentavalent immunisation (OR = 2.04, 1.63, 1.66, 1.18 respectively) compared to the non-accredited public facilities.
Similarly, the accredited facility was more likely to register maternity admissions, maternity deliveries, BCG immunisations and pentavalent immunisation (OR = 2.36, 1.76, 1.79, 1.26 respectively) compared to the non-accredited PNFP facilities. The difference in maternity admissions, maternity deliveries, BCG immunisations and pentavalent immunisation at the accredited facility were statistically significant, p < 0.05.
The maternal performance at the accredited facility may be explained by the increased community awareness of accreditation of the facility that resulted into increased utilization of the facility maternity and child health services. Our findings are in tandem with the results by El-Shal et al., who showed that accreditation in Egypt was associated with significant improvements in child morbidity, family planning, and delivery care [7]. Similarly, Chao-Wen et al., in South West China, reported improvements in in a new born screening program for indicators including new born health education provision, dried blood sampling, turnaround time, new born recall after positive primary screening following implementation of a comprehensive quality management system [32].
Reporting to dhis-2 performance
The accredited facility was more likely to report to dhis-2, data for hmis 10:01 (attendances, referrals) compared to the non-accredited public and PNFP facilities (OR = 1.17, 1.02 respectively). The difference in reporting for hmis 10:01 data at the accredited facility was statistically significant, p < 0.05.
In addition, the accredited facility was more likely to report to dhis-2, data for hmis 10:10 (laboratory) compared to the non-accredited PNFP facilities (OR = 1.04) and less likely compared to the non-accredited public facilities (OR = 0.74). The difference in reporting for hmis 10:10 data at the accredited facility was however not statistically significant, p > 0.05.
The reporting to dhis-2 performance may be explained by MoH requirement to the health facilities to report health care services performance through the dhis-2 system. The performance for reporting at the accredited facility may also be explained by the improved records & data management and compliance to the reporting standard operating procedures by MoH.
Our findings are in tandem with the results by Maddux et al., who showed increased compliance by 22% with reporting standards for accredited laboratories [33]. A similar study by Kibet et al., reported improvement in critical value reporting by 33 and 40% improvement for laboratory Turn Around Time following accreditation [34].
Results of this study complement what is stated within the literature about the positive impact of accreditation on quality improvement [35,36,37,38,39,40]. A systematic review that examined different aspects of the hospitals like bed sizes, geographic regions, teaching status, ownership, disease areas and service types reported that accreditation may have a positive impact on efficiency, safety, effectiveness, timeliness and patient-centeredness [41].
Whereas the benefits of accreditation are well documented, implementation and compliance to accreditation requirements are challenging and demanding, requiring active involvement from all key stakeholders to sustain the accreditation status [42, 43]. However, the investment in accreditation yields positive returns as demonstrated in this study.
This study had limitations including utilization of secondary data, as a result we could not eliminate bias from unobserved variables about the health facilities. A follow-up study with a more robust design, such as prospective cohort, should be conducted. In addition, the study was conducted within the period of the COVID-19 pandemic which also included the national lockdown. The lock down restricted patient movements, and impacted logistics and supply chain mechanisms which could have affected stock availability at the respective health facilities. It is possible that the health performance could have been higher than what was eventually captured.