Extending the measurement of quality beyond service delivery indicators.

Assessing the quality of healthcare services is a priority in low-resource and high-resource settings alike. It is, however, a complex endeavour. Outcome measures are subject to case-mix variation, often require lengthy follow-up periods to manifest, and are generally costly to monitor. Therefore, structure and process measures are routinely considered reliable alternatives under the assumption of a causal link between the provision of care and improved health status. In this edition of BMJ Global Health, Giorgio et al used such structure and process measures—that is, service delivery indicators (SDI)—to assess the quality of healthcare across 10 African countries.2 The SDI programme was set up to conduct crosssectional nationally representative surveys that examine service delivery performance in education and health in Africa. The health indicators assess health worker availability, health worker knowledge on the management of common ailments, and availability of selected essential equipment and treatments. These surveys are aimed at providing high-level snapshots of the quality of health services in target countries. In this editorial, we discuss some of the limits of using data from a platform such as the SDI programme to make sense of quality of care and highlight complementary approaches that are aligned with emergent thinking in the field.