Quality of Care for Under-Fives in First-Level Health Facilities in One District of Bangladesh

By Arifeen, S. E.; Bryce, J. et al. | Bulletin of the World Health Organization, April 2005 | Go to article overview

Quality of Care for Under-Fives in First-Level Health Facilities in One District of Bangladesh


Arifeen, S. E., Bryce, J., Gouws, E., Baqui, A. H., Black, R. E., Hoque, D. M. E., Chowdhury, E. K., Yunus, M., Begum, N., Akter, T., Siddique, A., Bulletin of the World Health Organization


Introduction

Each year over 10 million children in low- and middle-income countries die before their fifth birthday (1, 2). About half of these deaths are due to pneumonia, diarrhoea, malaria and measles (1). Undernutrition contributes to about 50% of these deaths (1, 3). Integrated Management of Childhood Illness (IMCI) is a strategy developed by WHO, the United Nations Children's Fund (UNICEF) and other technical partners to reduce mortality due to these causes and to undernutrition (4). By December 2002, IMCI had been introduced in 109 developing countries (5).

The IMCI strategy, includes guidelines for the management of sick children at first-level facilities. The guidelines are intended to improve care by ensuring a complete assessment of the child's health, and by providing algorithms that combine presenting symptoms into a set of illness classifications for management. The generic guidelines were validated and found to produce outcomes similar to those from expert paediatricians (4).

The multi-country evaluation of IMCI effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on child mortality, health and nutrition. MCE studies are under way in five countries (6, 7). Findings from other MCE sites have demonstrated that the introduction of IMCI in health Facilities can improve the quality of health care provided for children (8-10). Only in the Bangladesh site, however, was an assessment of the quality of care carried out prior to introducing IMCI. This study is particularly important in the light of several recent reports that have highlighted limited country-specific planning for implementation as a major reason why most countries have not successfully scaled up IMCI to reach coverage levels that would have an impact at the population level (11, 12).

The MCE evaluation in Bangladesh is a 7-year study that began in 2000. The study is being implemented in Matlab thana, a rural subdistrict in southern Bangladesh. Matlab has a population of about 500 000 and a mortality rate in children aged under 5 years of approximately 89 per 1000 live births. About 35% of these deaths can be attributed to causes directly addressed by IMCI, namely pneumonia, diarrhoea, measles and malnutrition (13). The IMCI evaluation is taking place in the four-fifths of the thana where health services are run by the Government of Bangladesh.

First-level government facilities in rural Bangladesh, and in the study area, are usually staffed by a paramedic (medical assistant/sub-assistant community medical officer (MA/SACMO))--usually male--who has had 4 years of clinical training, and a female reproductive health worker (family welfare visitor (FWV)) who has had 18 months of training in provision of maternal and child health and Family planning services. In some Facilities there is a position for a doctor, but in most cases, these positions remain vacant (14). There are no official user-fees for government-provided child health services. Bangladesh also has a wide range of local practitioners of indigenous and western medicine, and drug stores.

Because IMCI had not yet been fully implemented in Bangladesh, Matlab thana provided an excellent opportunity for a probability-design assessment of IMCI impact. The sampling frame included all 20 first-level government health facilities in the thana outside the International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B) intervention area, half of which were randomly selected for the implementation of IMCI. The data sources for the evaluation included baseline household and health facility surveys. Mid-term and final surveys will be conducted after IMCI has been fully implemented (6).

The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children aged under 5 years in the 20 first-level government health facilities to inform government planning and later evaluations of improvements in child health services and outcomes that may be associated with the introduction of IMCI. …

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