Challenges in Quality of Health Care in Children

Challenges in Quality of Health Care in Children

The Tour • • Introduction Defining ◦ Child Health ◦ Quality of Health Care • • 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 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) • • 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 Reducing the Infant Mortality rate to 30 • Reducing the Under 5 Mortality Rate to 62 •

Be Positive • • 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. • ◦ 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 • • • 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

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.

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 • • Lack of priority for children’s care quality prioritize 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 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 •

Common Specific Problems • Immunization • • • Hepatitis B Hib Pnemococcal, Rota virus Human papillomavirus (HPV) Gynecol. Oncol. 2010 May; vol. 117(2 Suppl) pp. S 32 -5. Global implementation of human papillomavirus (HPV) vaccine: lessons from hepatitis B vaccine.

Common Specific Problems • • • Immunization Hepatitis B Hib Pnemococcal, Rota virus HPV • Integrated Management of Childhood Illnesses (IMCI)

IMCI

Common Specific Problems • • • Immunization Hepatitis B Hib Pnemococcal, Rota virus HPV IMCI • Micronutrient supplement • • 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. J. Nutr. 2012 Jan; vol. 142(1) pp. 173 S-7 S Evidence for multiple micronutrient effects based on randomized controlled trials and meta-analyses in developing countries.

Common Specific Problems • • Immunization Hepatitis B Hib Pnemococcal, Rota virus HPV IMCI Micronutrient supplement • Newborn care detection and treatment of congenital infections • emergency cesarean section • newborn resuscitation • Kangaroo 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

• 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 Hepatitis B Hib Pnemococcal, Rota virus HPV IMCI Micronutrient supplement Newborn care • School health program • • 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 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 • • • Immunization Hepatitis B Hib Pnemococcal, Rota virus HPV IMCI Micronutrient supplement Newborn care School health program • HIV/AIDS First, 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 Problems • • • Immunization Hepatitis B Hib Pnemococcal, Rota virus HPV IMCI Micronutrient supplement Newborn care School health program HIV/AIDS services • Subspecialty 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. e 986 -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 • • • 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. • 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 • Immunization • Hepatitis B • Hib • Pnemococcal, Rota virus • HPV • IMCI • Micronutrient supplement • Newborn care • School health program • HIV/AIDS services • Subspecialty areas. • 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 • 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 Findings stage 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 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 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 Findings stage 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 Hosptials 3. Effectiveness: living with illness

Remedial Measures Topic Developmental Findings stage Remedial measures 4. Patient safety: Multiperspective Potential medical Birth to and surgical adolescence mistakes in hospitals and clinics Gross negligience, no supervision Hospital acquired infections Hospital infection Strengthen/ prevention unit establish units not functioning. Birth to adolesence Supervision, flow chart, evidence based guidance; NEPAS

Remedial Measures Topic Developmental Findings stage Remedial measures 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 ? Policy available in some cases Prioritize the care: NEPAS / Government 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: • 1. Quality of Health Care for Children and Adolescents: A Chartbook Sheilla Leatherman, Douglas Mccarthy. S. Unprogrammed Health Outcomes The University of North Carolina, Chapelhill. (2010) Pediatrics. 2011 Oct; vol. 128(4) pp. e 986 -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 Axelsson 3 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. LANCET 2011: 377; 505– 15 Published Online January 12, 2011 DOI: 10. 1016/S 0140 -6736(10)61894 -6 5. Child Health Status of Nepal: Social Exclusion Perspective Gurung G 1 Child 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