Bridging the diagnostic gap: diagnostic capacity and pediatric quality of care in LMICs.

BACKGROUND: Child mortality remains a major health burden in low- and middle-income countries (LMICs), where adherence to pediatric clinical guidelines is often suboptimal. Diagnostic capacity, the availability of essential laboratory and imaging tests, is a key structural input for delivering high-quality pediatric care, yet its relationship with quality of care has received limited empirical attention. This study examines the association between diagnostic capacity and adherence to evidence-based pediatric care guidelines across eight LMICs. METHODS: We analyzed nationally representative Service Provision Assessment (SPA) data from 5311 health facilities across eight LMICs (Afghanistan, the Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal, and Tanzania) collected between 2014 and 2022. Quality of care was assessed using a 10-item adherence index derived from direct observations of outpatient consultations, aligned with the WHO Integrated Management of Childhood Illness (IMCI) protocol. Diagnostic capacity was measured using a 16-item index reflecting the availability of essential laboratory and imaging tests recommended in the WHO Essential Diagnostics List. Associations between diagnostic capacity and adherence to clinical guidelines were examined using multilevel mixed-effects generalized linear models, adjusting for facility-, provider-, and patient-level covariates. RESULTS: Diagnostic capacity varied substantially across countries and facility levels. Among primary care facilities, median diagnostic availability ranged from 20.1% in Malawi to 72.4% in Senegal; among hospitals, from 64.7% in the Democratic Republic of the Congo to 88.5% in Ethiopia. On a 10-point scale, pediatric care quality scores were lowest in Afghanistan (3.45) and highest in DR Congo (4.89). Higher diagnostic capacity was significantly associated with greater adherence to pediatric clinical guidelines (adjusted log-odds β = 0.138; 95% CI: 0.061-0.216; p < 0.001). Sensitivity analyses using alternative outcome definitions, exposure measures, subgroup classifications, and model specifications yielded consistent results. CONCLUSIONS: This multi-country observational study identifies a positive association between diagnostic readiness and the quality of pediatric care in LMICs. These findings suggest that diagnostic capacity may serve as an enabling structural condition for delivering higher-quality pediatric care in LMICs, reinforcing the role of diagnostics within health system strengthening strategies.