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Publication date: 
June 18, 2018


Present methods to measure standardized, replicable, and comparable metrics to measure quality of medical care in low- and middle-income countries.


We constructed quality indicators for maternal, neonatal, and child care. To minimize reviewer judgment, we transformed criteria from checklists into data points and decisions into conditional algorithms. Distinct criteria were established for each facility level and type of care. Indicators were linked to discharge diagnoses. We designed electronic abstraction tools using computer-assisted personal interviewing software.


We present results for data collected in the poorest areas of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and the state of Chiapas in Mexico (January—October 2014).


We collected data from 12,662 medical records. Indicators show variations of quality of care between and within countries. Routine interventions, such as quality antenatal care (ANC), immediate neonatal care, and postpartum contraception, had low levels of compliance. Records that complied with quality ANC ranged from 68.8% [confidence interval (CI): 64.5–72.9] in Costa Rica to 5.7% [CI: 4.0–8.0] in Guatemala. Less than 25% of obstetric and neonatal complications were managed according to standards in all countries.


Our study underscores that, with adequate resources and technical expertise, collecting data for quality indicators at scale in low- and middle-income countries is possible. Our indicators offer a comparable, replicable and standardized framework to identify variations on quality of care. The indicators and methods described are highly transferable and could be used to measure quality of care in other countries.


Rios-Zertuche D, Zúñiga-Brenes P, Palmisano E, Hernández B, Schaefer A, Johanns CK, Gonzalez-Marmol A, Mokdad AH, Iriarte E. Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries. International Journal for Quality in Health Care. 18 June 2018; mzy136. doi:10.1093/intqhc/mzy136/503991