This paper adds to the overwhelming evidence on poor quality of health care, which is arguably the single greatest cause of avoidable death and suffering.
As is so often the case in this type of research, the design of the study does not tell us the underlying reasons for low quality of care. The authors hypothesise on knowledge deficits, lack of training, failure to apply appropriate practice even when such practice is known to the provider and is feasible, distance to referral facilities, and lack of motivation/incentive. We do not learn whether the healthcare providers have appropriate reference and learning materials...
CITATION: BMC Public Health. 2019 Dec 2;19(1):1608. doi: 10.1186/s12889-019-7853-3.
Quality of care for children with severe disease in the Democratic Republic of the Congo.
Clarke-Deelder E1, Shapira G2, Samaha H2, Fritsche GB2, Fink G3.
https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-78...
Abstract
BACKGROUND: Despite the almost universal adoption of Integrated Management of Childhood Illness (IMCI) guidelines for the diagnosis and treatment of sick children under the age of five in low- and middle-income countries, child mortality remains high in many settings. One possible explanation of the continued high mortality burden is lack of compliance with diagnostic and treatment protocols. We test this hypothesis in a sample of children with severe illness in the Democratic Republic of the Congo (DRC).
METHODS: One thousand one hundred eighty under-five clinical visits were observed across a regionally representative sample of 321 facilities in the DRC. Based on a detailed list of disease symptoms observed, patients with severe febrile disease (including malaria), severe pneumonia, and severe dehydration were identified. For all three disease categories, treatments were then compared to recommended case management following IMCI guidelines.
RESULTS: Out of 1180 under-five consultations observed, 332 patients (28%) had signs of severe febrile disease, 189 patients (16%) had signs of severe pneumonia, and 19 patients (2%) had signs of severe dehydration. Overall, providers gave the IMCI-recommended treatment in 42% of cases of these three severe diseases. Less than 15% of children with severe disease were recommended to receive in-patient care either in the facility they visited or in a higher-level facility.
CONCLUSIONS: These results suggest that adherence to IMCI protocols for severe disease remains remarkably low in the DRC. There is a critical need to identify and implement effective approaches for improving the quality of care for severely ill children in settings with high child mortality.
SELECTED EXTRACT
Our results suggest that critical information required for appropriate diagnosis is not collected by a majority of providers, which makes accurate diagnosis unlikely from the outset. Second, and maybe worse, even those providers who collect the most relevant pieces of information often fail to correctly diagnose health problems and severity. These limitations seem to be particularly pronounced for severe pneumonia or other respiratory infections, where only half of providers correctly classify cases as respiratory infections and less than one fifth of providers correctly classify them as severe. Maybe most troubling, even when the correct diagnosis is made – as is generally only the case for malaria – providers often fail to give appropriate medication. Last, across all three diseases, less than one fifth of severely ill children were recommended to urgently needed inpatient care, either in the facility they visited or at a higher-level facility.
Best wishes, Neil
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CHIFA profile: Neil Pakenham-Walsh is the coordinator of the HIFA campaign (Healthcare Information For All) and assistant moderator of the CHIFA forum. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org
