Challenges in Quality of Health Care in Children

The TourIntroductionDefiningChild Health Quality of Health CareWhere do Children Receive CareCode of EthicsMeasuring Quality of Health CareFactors Affecting the CarePresent Challenges on Specific IssuesRemedial MeasuresAcknowledgements

DefinitionsChild 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 )

DefinitionsQuality 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 definitionsChildren can not achieve optimal health alone.Antenatal, Natal and Post natal care.Foundation to adult healthLong term impact in its health and health care delivery system.

MILLENNIUM DEVELOPMENT GOALS (MDGs)

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 PlanReducing the Infant Mortality rate to 30Reducing the Under 5 Mortality Rate to 62

Be PositiveFalling IMRRising immunization coverageNew immunizationsDiarrhoeal admissions decreasedEarly diagnosis of pneumoniasCommunity neonatal careMalnutrition decreasingMore health care facilities

Will these tendencies continue?Reduce the child mortality to two-third by 2015.Disease burden on the Developing countries.PneumoniaDiarrhoeaMalariaMeaslesHIV/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 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 ChildrenConsistent with Professional KnowledgeDesired Health Outcomes

Challenges in Measuring Quality Health Care for ChildrenLack of evidence Expert recommendations Quality measurement Quality of personal health care servicesPaucity of representative data condition-specific approach Childs perspective

Code of EthicsMedical Education.Utilizing Mass Media.Regulation and standard setting.

Inequality of Health Care in ChildrenPoor-rich disparities.Developmental regions disparities.Rural and urban disparitiesGender disparitiesDemand for health careOut-of-pocket expenditureStreet children and child labour.

Inequality in Health

Inequality in Health

The Problem of Street Children and Child Labour

AbuseChild LabourMalnutrition Vaccination Diseases

Challenges in Quality Care for ChildrenLack of priority for childrens care qualityprioritize based on "services that modify health states to future morbidity and mortality"Fragmentation of health care delivery and financing.Insufficient professional skill or confidence.1.quality improvement skills as core competency2. interactive skills3. computerized prompts

Private sectors influencing child health.

Policy translating better health outcomes

Better Harness to Improve Quality Health Care for ChildrenGovernmentCommercialization and social marketingInformation dissemination and training.Contracting

Common Specific ProblemsImmunizationHepatitis BHibPnemococcal, 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 ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIntegrated Management of Childhood Illnesses (IMCI)

IMCI

Common Specific ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIMCIMicronutrient supplementreveal 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.

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.

Common Specific ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIMCIMicronutrient supplementNewborn caredetection and treatment of congenital infectionsemergency cesarean sectionnewborn resuscitationKangaroo mother care

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?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

simple, evidence.....The trials build on the findings of a cluster-randomised 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 066; 95% CI 046095).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-randomised trial. Lancet 2006; 367: 91018.

Common Specific ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIMCIMicronutrient supplementNewborn careSchool health programconsistent 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 non-participants

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 ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIMCIMicronutrient supplementNewborn careSchool health programHIV/AIDSFirst, retention in care within the decentralizing network of services.Second, both magnitude and determinants of patient retention vary substantially.Third, socio-structural factors.

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.

Common Specific ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIMCIMicronutrient supplementNewborn careSchool health programHIV/AIDS servicesSubspecialty areas.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

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 ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIMCIMicronutrient supplementNewborn careSchool health programHIV/AIDS servicesSubspecialty areas.Pediatric Surgical Caresevere manpower shortage, high pediatric surgeon workload, and poor facilities.J. Pediatr. Surg. 2010 Mar; vol. 45(3) pp. 610-8. Challenges of training and delivery of pediatric surgical services in Africa

Common Specific ProblemsImmunizationHepatitis BHibPnemococcal, Rota virusHPVIMCIMicronutrient supplementNewborn careSchool health programHIV/AIDS servicesSubspecialty areas.Pediatric Surgical CareLaboratory 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

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

TopicDevelopmental stageFindingsRemedial measuresI. Effectiveness staying HealthyImmunizationsBirth to AdolescenceBooster dose and Extra EPI negligibleEducate parents- NEPAS role

Guidance on child rearing practicesBirth to 36 monthsNot functioningEstablish in Teaching Hosp. Hospitals HospitalsNEPAS-NESOG

Recommended health care visitBirth to AdolescenceNegligible servicesStart in Teaching Hosp. Hospitals

Remedial Measures

TopicDevelopmental stageFindingsRemedial measuresI. Effectiveness staying HealthySpeech and language assessment guidance4-35 monthsNot establishedEstablish Paediatric- child psychiatry-ENT clinic in Teaching Hospitals

Counselling Adolescent in healthy behaviorsAdolescentNot establishedEstablish in Teaching Hospitals

Safe water supply, hand washing and healthy dietBirth to adolescentPartially established but not effectiveStrengthen present nutrition unit, NEPAS role

Remedial Measures

TopicDevelopmental stageFindingsRemedial measures2. Effectiveness: getting better when sick or injuredInappropriate treatmentBirth to adolescenceMany: antibiotics for cold, wrong diagnosis, no counseling, inappropriate investigationsSupervision, NMC examination standarization, private paramedical campuses standarization

Inappropriately equipped health facilityBirth to adolecenceUnavailability of beds for critical pediatric careGovernment to form policy and allocate budget , etc

Remedial Measures

TopicDevelopmental stageFindingsRemedial measures3. Effectiveness: living with illnessChronic illnesses: Childhood to adolescenceNegligible servicesEstablish subspecialty clinics, NEPASMental Health careMiddle childhood to adolescenceNegligible servicesEstablish pediatric pshychiatry services in Teaching Hosp. Hosptials

Remedial Measures

TopicDevelopmental stageFindingsRemedial measures4. Patient safety: Multi-perspectivePotential medical and surgical mistakes in hospitals and clinicsBirth to adolescenceGross negligience, no supervisionSupervision, flow chart, evidence based guidance; NEPAS

Hospital acquired infectionsBirth to adolesenceHospital infection prevention unit not functioning.Strengthen/ establish units

Remedial Measures

TopicDevelopmental stageFindingsRemedial measures5. Access and timeliness/Patient and family centerlines: Living with illness.National goal for children with special care needsEarly childhood to adolescence? Policy available in some casesPrioritize the care: NEPAS / Government

Parent perceptions of interpersonal Quality of careEarly childhood to adolescence33 % reported professional did not communicate well (USA)Training and motivation.

SummaryThe 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.

SummaryThe 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 informationFinally many of our programs are financed by external sources, and with the financial instability these are going to be more costly.

Acknowledgements:

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 J2. 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, 2:84.. India: Towards Universal Health Coverage; Health care and equity in India.Y Balarajan, S Selvaraj, S V Subramanian. LANCET2011: 377; 50515 Published Online January 12, 2011DOI:10.1016/S0140-6736(10)61894-65. 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.

Thank youThis Presentation is Freely Available at www.prsharma.com.np

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