Background

1. An Assessment of Hospital Care for Children Under-five at District and Sub-District Level Hospitals in Bangladesh

2. Background • IMCI has been institutionalized in the public health system in Bangladesh, with facility based IMCI expanded to more than 2/3 of the country • IMCI advocates referral of severely ill children, and increasingly more sick children in Bangladesh are being referred as severe cases (10-15%) to sub-district (upazila) or district hospitals for appropriate management • Child survival interventions thus, critically depend on functioning referral systems and good care at referral facilities • Assessment is needed as part of initiating quality improvement process as there is limited information available on the quality of care in hospitals

3. WHO: Framework for Hospital Improvement Process 1. Country Orientation 2. Hospital Assessment (Baseline) 3. Agreement on standards 4. Definition of interventions & area PLAN 5. Improvement in hospitals • 7. Sharing of • Information DO ACT CHECK 6. Monitoring and Evaluation

4. Process • Adaptation Of Tools • WHO Generic hospital assessment tools were reviewed, adapted • Sections Of Tools • Hospital layout, essential drugs, supplies and equipment • Laboratory support • Emergency area and emergency management • Neonatal care and case management for ARI, Diarrhoea, febrile illness and malnutrition • Supportive care and monitoring • Hospital administration • Measure of access to hospital care • Quality of care • Field Testing of tools • Training of the assessors

5. Process (cont.) Sampling of hospitals Selection of district hospitals (DHs):One district was randomly selected from each division, for a total of six DHs. Selection of sub-district hospitals:Two facilities were selected from each of the six selected districts based on stratified sampling

6. Process (cont.) • Assessment of hospitals • Each assessment team consisting of 2 paediatricians and 2 programme personnel visited each site for 2 days in May 2009 • Source of information for assessing quality • Observation of clinical case management • Reviewing records when there were not sufficient patients for direct case observations • Interviews with hospital staff and, if needed, simulated cases when no case could be observed nor record could be found • Extraction of the data from Management Information System (MIS) report

7. Process (cont.) • Scoring system for assessment • Hospital assessment tool comprised of 11 sections • For individual and overall scoring, points from 5 to 1 were awarded: • 5 - Good practice complying with standards of care, • 4 - Showing little need for improvement to reach standard care, • 3 - Meaning some need for improvement, • 2 - Indicating considerable need for improvement and • 1 - Services not provided, totally inadequate care or potentially life-threatening practices.

13. Key Findings

14. Major reasons for under five visits at hospital in 2008 Source: Hospital Routine MIS

15. Hospital layout and child health infrastructure • All of the 6 DHs had separate paediatric corner and designated beds for children • Among the 12 Sub-district hospitals (SDH), 7 had a separate paediatric corner, and only 2 had designated beds for admitting children • Half of DHs and one-third of SDHs had paediatric surgery facilities, none had paediatric surgeons • All of the 18 facilities had 24-hour nursing care for admitted children

16. Hospital support system, equipment and drugs • Backup power supply was available only at one DH and 4 SDHs • 5 DHs and 8 SDHs had coloured bins for waste disposal but appropriate waste disposal was practiced only in half • Running water was available but provision of safe drinking water only at half of the facilities • At least one injectable antibiotic for managing severe pneumonia or very severe disease (Ampicillin or Gentamycine) was available at all DHs, but not at all SDHs even though both are required • Only one DH had all of the essential paediatric inpatient drugs (normal saline, injection Ampicillin, injection Gentamycine, cholera saline, syrup Amoxicillin and injection Amoxicillin) • Filled oxygen cylinders were available at all the visited hospitals, although 3 SDHs had no flow-meter

17. Quality of laboratory support

18. Availability and quality of Neonatal care

19. Quality of case management: Pneumonia

20. Quality of case management: Diarrhoea

21. Quality of case management: severe malnutrition

22. Patient Monitoring System

23. Hospital administration

24. Key Findings • There is no established TRIAGE system in any of the hospitals • The provision of neonatal care services, especially in Sub-district hospitals, requires substantial improvement • Essential laboratory supports were found to be adequate at almost all district hospitals but requires substantial improvement at majority of SDHs • Weak monitoring systems and inadequate provision of care for major killers especially pneumonia, diarrhoea, and malnutrition

25. Major Recommendations • Urgent need to address the following priority areas: • Staffing • Clinical competency in case-management and supportive care • Triaging systems • Essential drugs and supplies including newborn care equipments • Establishment of Quality Assurance system • Documentation of monitoring and assessments

26. Other Recommendations • National benchmarking or hospital accreditation system for an integrated quality improvement approach • Build capacities of currently available manpower in managing newborn and sick children with standard treatment and monitoring guidelines • Creating and maintaining a master database of essential drugs and equipment may facilitate monitoring, planning and action within facilities • Reassessment of the current allocation of resources to focus district and sub-district hospital

27. Limitations • Out of 61 district and 324 Upazila hospitals in Bangladesh, the assessment process covered only 18 facilities • Not all practices could be observed due to time constraints and lack of cases during the visits • Poor quality of patients records hindered proper assessment of existing practices • Inter-observer variability in perception of the hospital performance • Hawthrone effect • Scoring system itself

28. Baseline assessment completed WHO Pocket book adapted based on agreed standards Development of SOP for MNH in process Training package for ETAT developed and facility based newborn care initiated Priority districts identified for interventions Progress of Hospital Improvement process in Bangladesh

30. Acknowledgements • IMCI section of the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh • SEARO/WHO for their technical assistance and financial support • Bangladesh Paediatric Association (BPA) for their support and technical guidance