Transcript Challenges in Quality of Health Care in Children

Challenges in Quality of
Health Care in Children
The Tour
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Introduction
Defining
Child Health
Quality of Health Care
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Where do Children Receive Care
Code of Ethics
Measuring Quality of Health Care
Factors Affecting the Care
Present Challenges on Specific Issues
Remedial Measures
Acknowledgements
Definitions
• Child health is a state of physical,
mental, intellectual, social and
emotional well-being and not merely the
absence of disease or infirmity. Healthy
children live in families, environments,
and communities that provide them with
the opportunity to reach their fullest
developmental potential.
• (Health Workgroup, First Things First, October, 2007
)
Definitions
 Quality
of health care is the degree to
which health services for individuals
and populations increase the likelihood
of desired health outcomes and are
consistent with current professional
knowledge”
(IOM 1990)
Important aspects of these definitions
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Children can not achieve optimal
health alone.
Antenatal, Natal and Post natal care.
Foundation to adult health
Long term impact in its health and
health care delivery system.
MILLENNIUM DEVELOPMENT GOALS (MDGs)
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Goal 1. Eradicate extreme poverty and hunger
Goal 2. Achieve universal primary education
Goal 3. Promote gender equality and empower
women
Goal 4. Reduce child mortality
Goal 5. Improve maternal health
Goal 6. Combat HIV/AIDS, Malaria and other diseases
Goal 7. Ensure environmental sustainability
Goal 8. Develop a global partnership for development
1997-2017 Plan
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Reducing the Infant Mortality rate
to 30
Reducing the Under 5 Mortality
Rate to 62
Be Positive
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Falling IMR
Rising immunization coverage
New immunizations
Diarrhoeal admissions decreased
Early diagnosis of pneumonias
Community neonatal care
Malnutrition decreasing
More health care facilities
Will these tendencies continue?
Reduce the child mortality to two-third by
2015.
 Disease burden on the Developing
countries.
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Pneumonia
Diarrhoea
Malaria
Measles
HIV/AIDS
Half a billion children could grow up physically and mentally
stunted over the next 15 years because they do not have
enough to eat: Save the Children
One parent in six said their children were abandoning school
to help out by working for food.
Where do Sick Children Receive
Care?
Where do Sick Children Receive
Care?
Defining Quality of Health Care for
Children
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Children have different demographics
than adults.
Children undergo rapid and continuous
developmental change.
Children have different disease patterns
and manifestations than adults.
Children are dependent on their parents
or other caregivers.
School health services.
Measuring
Quality of Health
Care in Children
Organizational
leadership,
Culture,
Information
•Structural
Technical
proficiency,
Interactions
with patients
•Process
Children's
Development,
Well being,
Family
satisfaction
•Outcomes
Consistent with Professional Knowledge
Desired Health Outcomes
Challenges in Measuring Quality
Health Care for Children
Lack of evidence
 Expert recommendations
 Quality measurement
 Quality of personal health care services
 Paucity of representative data
 condition-specific approach
 Child’s perspective
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Code of Ethics
Medical Education.
Utilizing Mass Media.
Regulation and standard setting.
Inequality of Health Care in Children
Poor-rich disparities.
 Developmental regions disparities.
 Rural and urban disparities
 Gender disparities
 Demand for health care
 Out-of-pocket expenditure
 Street children and child labour.
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Inequality in Health
Inequality in Health
The
Problem
of
Street Children and
Child Labour
• Abuse
• Child Labour
• Malnutrition
• Vaccination
• Diseases
Challenges in Quality Care for
Children
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Lack of priority for children’s care quality
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prioritize based on "services that modify health states
to future morbidity and mortality"
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Fragmentation of health care delivery and
financing.
Insufficient professional skill or confidence.
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1.quality improvement skills as core
competency
2. interactive skills
3. computerized prompts
Private sectors influencing child health.
Policy translating better health
outcomes
Better Harness to Improve Quality
Health Care for Children
Government
 Commercialization and social
marketing
 Information dissemination and
training.
 Contracting
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Common Specific Problems
 Immunization
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•
Hepatitis B
Hib
Pnemococcal, Rota virus
Human papillomavirus (HPV)
Gynecol. Oncol. 2010 May; vol. 117(2 Suppl) pp. S32-5. Global implementation of human papillomavirus (HPV) vaccine: lessons from
hepatitis
B
vaccine.
Common Specific Problems
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Immunization
Hepatitis B
Hib
Pnemococcal, Rota virus
HPV
 Integrated
Management of
Childhood Illnesses (IMCI)
IMCI
Common Specific Problems
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Immunization
Hepatitis B
Hib
Pnemococcal, Rota virus
HPV
IMCI
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Micronutrient supplement
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reveal a modest but significant increase in birth weight,
reduction in low birth weight but no impact on preterm
birth or perinatal mortality. In children, small effect sizes
of 0.13 for length/height and 0.14 for weight have been
shown with 3 or more micronutrients compared to fewer
micronutrients.
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J. Nutr. 2012 Jan; vol. 142(1) pp. 173S-7S Evidence for multiple micronutrient effects based on randomized controlled trials and meta-analyses in developing countries.
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Common Specific Problems
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Immunization
Hepatitis B
Hib
Pnemococcal, Rota virus
HPV
IMCI
Micronutrient supplement
 Newborn
care
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detection and treatment of
congenital infections
emergency cesarean section
newborn resuscitation
Kangaroo mother care
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Semin. Perinatol. 2010 Dec; vol. 34(6) pp. 477-85.Why is continuum of care from home to health facilities essential to improve perinatal survival?
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J Perinatol. 2011 May; vol. 31(5) pp. 361-7. Community Kangaroo Mother Care: implementation and potential for neonatal survival and health in very low-income settings
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• The trials build on the
findings of a clusterrandomised controlled trial
in Nepal, which compared
chlorhexidine application
with education on dry cord
care and showed an
apparent effect on
neonatal mortality of
chlorhexidine application
in a subgroup enrolled
within 24 h of birth
(relative risk 0·66; 95% CI
0·46–0·95).
simple, evidence.....
• Mullany L, Darmstadt G, Khatry
S, et al. Topical applications of
chlorhexidine to the umbilical
cord for prevention of
omphalitis and neonatal
mortality in southern Nepal: a
community-based, cluster-
Common Specific Problems
Immunization
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Hepatitis B
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Hib
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Pnemococcal, Rota virus
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HPV
 IMCI
 Micronutrient supplement
 Newborn care
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 School
health program
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consistent positive effects of school feeding in its
different modalities on energy intake, micronutrient
status, school enrollment, and attendance of the
children participating in SFPs compared to nonparticipants
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Nutr. Rev. 2011 Feb; vol. 69(2) pp. 83-98. School feeding programs in developing countries: impacts on children's health and educational outcomes.
Common Specific Problems
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Immunization
Hepatitis B
Hib
Pnemococcal, Rota virus
HPV
IMCI
Micronutrient supplement
Newborn care
School health program
 HIV/AIDS
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First, retention in care within the decentralizing network of
services.
Second, both magnitude and determinants of patient
retention vary substantially.
Third, socio-structural factors.
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Curr HIV/AIDS Rep. 2010 Nov; vol. 7(4) pp. 234-44. Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions.
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Common Specific Problems
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Immunization
Hepatitis B
Hib
Pnemococcal, Rota virus
HPV
IMCI
Micronutrient supplement
Newborn care
School health program
HIV/AIDS services
 Subspecialty
areas.
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Those working in the PICU in resource-poor nations
perpetually face the challenges of ulack of expert support
(subspecialists), diagnostic facilities (laboratory and
radiology), and appropriate medications and equipment
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Pediatrics. 2011 Oct; vol. 128(4) pp. e986-92 Challenges in setting up pediatric and neonatal intensive care units in a resource-limited country. Basnet S, Adhikari N, Koirala J
Common Specific Problems
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Immunization
Hepatitis B
Hib
Pnemococcal, Rota virus
HPV
IMCI
Micronutrient supplement
Newborn care
School health program
HIV/AIDS services
Subspecialty areas.
 Pediatric
Surgical Care
 severe
manpower shortage, high pediatric
surgeon workload, and poor facilities.
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J. Pediatr. Surg. 2010 Mar; vol. 45(3) pp. 610-8. Challenges of training and delivery of pediatric surgical services in Africa
Common Specific Problems
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Immunization
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Hepatitis B
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Hib
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Pnemococcal, Rota virus
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HPV
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IMCI
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Micronutrient supplement
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Newborn care
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School health program
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HIV/AIDS services
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Subspecialty areas.
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Pediatric Surgical Care
 Laboratory services
 (1) developing integrative national laboratory strategic plans
and policies and building systems to address multiple diseases;
 (2) establishing public-private partnerships;
 (3) ensuring effective leadership, commitment, and coordination
 (4) establishing and/or strengthening centers of excellence
 (5) establishing affordable, scalable, and effective laboratory
accreditation scheme
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Am. J. Clin. Pathol. 2010 Sep; vol. 134(3) pp. 368-73. Laboratory systems and services are critical in global health: time to end the neglect?
Remedial Measures
Topic
Developmental
stage
Findings
Remedial
measures
Immunizations
Birth to
Adolescence
Booster dose
and Extra EPI
negligible
Educate
parents- NEPAS
role
Guidance on
child rearing
practices
Birth to 36
months
Not functioning
Establish in
Teaching Hosp.
Hospitals
Hospitals
NEPAS-NESOG
Recommended
Birth to
Negligible
Start in
I. Effectiveness
staying Healthy
Remedial Measures
Topic
Developmental
stage
Findings
Remedial
measures
4-35 months
Not established
Establish
Paediatric- child
psychiatry-ENT
clinic in Teaching
Hospitals
Counselling
Adolescent
Adolescent in
healthy behaviors
Not established
Establish in
Teaching
Hospitals
Safe water supply, Birth to
hand washing and adolescent
healthy diet
Partially
established but
not effective
Strengthen
present nutrition
unit, NEPAS role
I. Effectiveness
staying Healthy
Speech and
language
assessment
guidance
Remedial Measures
Topic
Developmental
stage
Findings
Remedial
measures
Inappropriate
treatment
Birth to
adolescence
Many: antibiotics
for cold, wrong
diagnosis, no
counseling,
inappropriate
investigations
Supervision, NMC
examination
standarization,
private paramedical
campuses
standarization
Inappropriately
equipped health
facility
Birth to
adolecence
Unavailability of
beds for critical
pediatric care
Government to
form policy and
allocate budget , etc
2. Effectiveness:
getting better
when sick or
injured
Remedial Measures
Topic
Developmental
stage
Findings
Remedial
measures
Chronic
illnesses:
Childhood to
adolescence
Negligible
services
Establish
subspecialty
clinics, NEPAS
Mental Health
care
Middle
childhood to
adolescence
Negligible
services
Establish
pediatric
pshychiatry
services in
Teaching Hosp.
Hosptials
3. Effectiveness:
living with
illness
Remedial Measures
Topic
Developmental
stage
Findings
Remedial
measures
Potential medical Birth to
and surgical
adolescence
mistakes in
hospitals and
clinics
Gross
negligience, no
supervision
Supervision,
flow chart,
evidence based
guidance;
NEPAS
Hospital
acquired
infections
Hospital infection Strengthen/
prevention unit
establish units
not functioning.
4. Patient safety:
Multiperspective
Birth to
adolesence
Remedial Measures
Topic
Developmental
stage
Findings
Remedial
measures
? Policy
available in
some cases
Prioritize the
care: NEPAS /
Government
5. Access and
timeliness/Patien
t and family
centerlines:
Living with
illness.
National goal for
Early childhood
children with
to adolescence
special care needs
Parent
perceptions of
interpersonal
Quality of care
Early childhood 33 % reported
Training and
to adolescence professional did motivation.
not communicate
well (USA)
Summary
• The quality of child care can
be a critical influence on the
well being of neonate,
infants, toddlers and school
going children.
• It is recognized that
increasing access to services
is vital.
• The geography and terrain of
the country remains a great
obstacle.
Summary
• The issue of human resources is a
major challenge.
• The Millennium Development
Goals for child health will re-quire
substantial commitments from
Government, NGOs and
professional organizations.
• Contracting, regulation, social
marketing, and training and
dissemination of information
• Finally many of our programs are
financed by external sources, and
with the financial instability these
are going to be more costly.
Acknowledgements:
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1. Quality of Health Care for Children and Adolescents: A Chartbook Sheilla Leatherman,
Douglas MccarthyS. Unprogrammed Health Outcomes The University of North Carolina,
Chapelhill. (2010)
Pediatrics. 2011 Oct; vol. 128(4) pp. e986-92 Challenges in setting up pediatric and
neonatal intensive care units in a resource-limited country. Basnet S, Adhikari N, Koirala
J
2. Can developing countries achieve adequate improvements in child health outcomes
without engaging the private sector? Flavia Bustreo,1 April Harding,2 & Henrik
Axelsson3 Bulletin of the World Health Organization 2003, 81 (12).
3. Measuring health inequality among children in developing countries: does the choice
of the indicator of economic status matter? Tanja AJ Houweling, Anton E Kunst and
Johan P Mackenbach. International Journal for Equity in Health 2003, 2:8
4.. India: Towards Universal Health Coverage; Health care and equity in India.
Y Balarajan, S Selvaraj, S V Subramanian. LANCET2011: 377; 505–15 Published Online
January 12, 2011DOI:10.1016/S0140-6736(10)61894-6
5. Child Health Status of Nepal: Social Exclusion Perspective Gurung G1Child Health
Status of Nepal: Social Exclusion Perspective. J. Nepal Paediatr. Soc. Vol 29, No. 2.
6. Millennium development Goals: Need Assessment for Nepal.
7. Child Health - Definition Health Workgroup, First Things First, October, 2007
8. Annual Report. Department of Health Services . 2066/67 (2009/10). Government of
Nepal.
9. Dr Parag Bhattarai MD, FAAP. Wykoff Hospital, New York.
This Presentation is
Freely Available at
www.prsharma.com.np
Thank you
“We want to move Johnny to a place where there
are none but children; a place set up on purpose
for sick children; where the good doctors and
nurses pass their lives with children, talk to none
but children, touch none but children, comfort and
cure none but children. Is there really such a
place?”
– Charles Dickens, Our Mutual Friend,
December 1864