Assessing the quality of care for children attending health facilities: a systematic review of assessment tools

Private sector quality of care for maternal, new-born, and child health in low-and-middle-income countries: a secondary review

The private sector has emerged as a crucial source of maternal, newborn, and child health (MNCH) care in many low- and middle-income countries (LMICs). Quality within the MNCH private sector varies and has not been established systematically. This study systematically reviews findings on private-sector delivery of quality MNCH care in LMICs through the six domains of quality care (QoC) (i.e., efficiency, equity, effectiveness, people-centered care, safety, and timeliness). We registered the systematic review with PROSPERO international prospective register of systematic reviews (registration number CRD42019143383) and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement for clear and transparent reporting of systematic reviews and meta-analyses. Searches were conducted in eight electronic databases and two websites. For inclusion, studies in LMICs must have examined at least one of the following outcomes using qualitative, quantitative, and/or mixed-methods: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, child mortality, service utilization, quality of care, and/or experience of care including respectful care. Outcome data was extracted for descriptive statistics and thematic analysis. Of the 139 included studies, 110 studies reported data on QoC. Most studies reporting on QoC occurred in India (19.3%), Uganda (12.3%), and Bangladesh (8.8%). Effectiveness was the most widely measured quality domain with 55 data points, followed by people-centered care (n = 52), safety (n = 47), timeliness (n = 31), equity (n = 24), and efficiency (n = 4). The review showed inconsistencies in care quality across private and public facilities, with quality varying across the six domains. Factors such as training, guidelines, and technical competence influenced the quality. There were also variations in how domains like "people-centered care" have been understood and measured over time. The review underscores the need for clearer definitions of "quality" and practical QoC measures, central to the success of Sustainable Development Goals (SDGs) and equitable health outcomes. This research addresses how quality MNCH care has been defined and operationalized to understand how quality is delivered across the private health sector and the larger health system. Numerous variables and metrics under each QoC domain highlight the difficulty in systematizing QoC. These findings have practical significance to both researchers and policymakers.

Systematic Review Registration

https://bmjopen.bmj.com/content/10/2/e033141.long, Identifier [CRD42019143383].

Quality of sick child management by health extension workers: role of a complex improvement intervention

BACKGROUND

Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers.

METHODS

The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2-59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses.

RESULTS

We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention.

CONCLUSION

The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities.

TRIAL REGISTRATION NUMBER

ISRCTN12040912, retrospectively registered on 19/12/ 2017.

Quality of care for children with acute respiratory infections in health facilities: a comparative analysis of assessment tools

Background

Severe childhood pneumonia requires treatment in hospital by trained health care workers. It is therefore important to determine if health facilities provide quality health services for children with acute respiratory infections (ARI), including pneumonia. Using established indicators from WHO to measure quality of care (QoC) as a reference standard, this review aims to evaluate how well existing tools assess QoC for children presenting to health facilities with ARI.

Methods

Existing assessment tools identified from a published systematic literature review that evaluated QoC assessment tools for children (<15 years) in health facilities for all health conditions were included in this ARI-specific review. 27 ARI-specific indicators or “quality measures” from the WHO “Standards for improving quality of care for children and young adolescents in health facilities” were selected for use as a reference standard to assess QoC for children presenting to health facilities with ARI symptoms. Each included assessment tool was evaluated independently by two paediatricians to determine how many of the WHO ARI quality measures were assessable by the tool. The assessment tools were then ranked in order of percentage of ARI quality measures assessable.

Results

Nine assessment tools that assessed QoC for children attending health facilities were included. Two hospital care tools developed by WHO had the most consistency with ARI-specific indicators, assessing 22/27 (81.5%) and 20/27 (74.1%) of the quality measures. The remaining tools were less consistent with the ARI-specific indicators, including between zero to 16 of the 27 quality measures. The most common indicators absent from the tools were assessment of appropriate use of pulse oximetry and administration of oxygen, how often oxygen supply was unavailable, and mortality rates.

Conclusions

The existing WHO hospital-based QoC assessment tools are comprehensive but could be enhanced by improved data quality around oxygen availability and appropriate use of pulse oximetry and oxygen administration. Any tools, however, should be considered within broader assessments of QoC, rather than utilised in isolation. Further adaptation to local settings will improve feasibility and facilitate progress in the delivery of quality health care for children with ARI.

Registration

The protocol of the original systematic review was registered in PROSPERO ID: CRD42020175652.

Baseline assessment of the WHO/UNICEF/UNFPA maternal and newborn quality-of-care standards around childbirth: Results from an intermediate hospital, northeast Namibia

BACKGROUND

Quality of care around childbirth can reduce above half of the stillbirths and newborn deaths. Northeast Namibia's neonatal mortality is higher than the national level. Yet, no review exists on the quality of care provided around childbirth. This paper reports on baseline assessment for implementing WHO/UNICEF/UNFPA quality measures around childbirth.

METHODS

A mixed-methods research design was used to assess quality of care around childbirth. To obtain good saturation and adequate women opinions, we purposively sampled the only high-volume hospital in northeast Namibia; observed 53 women at admission, of which 19 progressed to deliver on the same day/hours of data collection; and interviewed 20 staff and 100 women who were discharged after delivery. The sampled hospital accounted for half of all deliveries in that region and had a high (27/1,000) neonatal mortality rate above the national (20/1,000) level. We systematically sampled every 22nd delivery until the 259 mother-baby pair was reached. Data were collected using the Every Mother Every Newborn assessment tool, entered, and analyzed using SPSS V.27. Descriptive statistics was used, and results were summarized into tables and graphs.

RESULTS

We reviewed 259 mother-baby pair records. Blood pressure, pulse, and temperature measurements were done in 98% of observed women and 90% of interviewed women at discharge. Above 80% of human and essential physical resources were adequately available. Gaps were identified within the WHO/UNICEF/UNFPA quality standard 1, a quality statement on routine postpartum and postnatal newborn care (1.1c), and also within standards 4, 5, and 6 on provider-client interactions (4.1), information sharing (5.3), and companionship (6.1). Only 45% of staff received in-service training/refresher on postnatal care and breastfeeding. Most mothers were not informed about breastfeeding (52%), postpartum care and hygiene (59%), and family planning (72%). On average, 49% of newborn postnatal care interventions (1.1c) were practiced. Few mothers (0-12%) could mention any newborn danger signs.

CONCLUSION

This is the first study in Namibia to assess WHO/UNICEF/UNFPA quality-of-care measures around childbirth. Measurement of provider-client interactions and information sharing revealed significant deficiencies in this aspect of care that negatively affected the client's experience of care. To achieve reductions in neonatal death, improved training in communication skills to educate clients is likely to have a major positive and relatively low-cost impact.

Monitoring healthcare improvement for mothers and newborns: A quantitative review of WHO/UNICEF/UNFPA standards using Every Mother Every Newborn assessment tools

BACKGROUND

Assessment tools with the ability to capture WHO/UNICEF/UNFPA standard quality-of-care measures are needed. This study aimed to assess the ability of Every Mother Every Newborn (EMEN) tools to capture WHO/UNICEF/UNFPA maternal and newborn quality improvement standard indicators.

METHODS

A quantitative study using the EMEN quality assessment framework was applied. The six EMEN tools were compared with the WHO/UNICEF/UNFPA maternal and newborn quality improvement standards. Descriptive statistics analysis was carried out with summaries using tables and figures.

RESULTS

Overall, across all EMEN tools, 100% (164 of 164) input, 94% (103 of 110) output, and 97% (76 of 78) outcome measures were assessed. Standard 2 measures, i.e., actionable information systems, were 100% (17 of 17) completely assessed by the management interview, with 72% to 96% of standard 4-6 measures, i.e., client experiences of care, fulfilled by an exit interview tool.

CONCLUSION

The EMEN tools can reasonably measure WHO/UNICEF/UNFPA quality standards. There was a high capacity of the tools to capture enabling policy environment and experiences of care measures not covered in other available tools which are used to measure the quality of care.