Quality improvement and the integrated management of childhood illness: lessons from developed countries.

BACKGROUND: The World Health Organization (WHO) and the United Nations Children's Fund have launched a global initiative to reform the health care received by sick children in developing countries. The core of this initiative, known as Integrated Management of Childhood Illness (IMCI), is a clinical practice guideline. The guideline addresses the case management of clinically ill children under the conditions typical of peripheral facilities, focusing on the most common serious conditions, such as pneumonia and malaria. WHO estimates that up to 70% of childhood deaths in developing countries are attributable to conditions addressed by IMCI. About 40 developing countries have made commitments to implementing IMCI in public-sector programs. QI STRATEGIES AND GUIDELINES IN DEVELOPING COUNTRIES: Like other clinical guidelines, which are increasingly accepted in developing countries' health programs, IMCI raises difficult quality issues. High levels of guideline compliance are needed for IMCI to be effective. However, many developing countries have achieved relatively low levels of compliance with far simpler guidelines, such as those for diarrhea case management. Despite obvious differences, the experience of developed countries in quality improvement (QI) offers a wide range of promising strategies for IMCI, including (1) developing standards, (2) communicating those standards to providers, (3) monitoring quality and providing feedback, (4) team-based QI problem solving, (5) designing processes conducive to high levels of quality, and (6) regulating providers and institutions. MORE LESSONS FROM DEVELOPED COUNTRIES FOR IMCI: Only recently have QI strategies been adapted for use in developing countries, and virtually none of the early experience has dealt with IMCI. Indirect evidence suggests that a wide range of QI approaches will prove suitable for IMCI. However, it will be important to carefully evaluate the cost-effectiveness of early applications. The experience of developed countries also provides useful models for important issues that have not yet been addressed by the IMCI initiative. These issues include (1) the review and possible modification of the current guideline, (2) extending IMCI into the private sector through regulatory strategies, and (3) institutionalizing QI.

Low-cost health delivery systems: lessons from Nicaragua.

In 1976 the Ministry of Health of Nicaragua began a low cost program to deliver simple health services in rural areas through trained traditional birth attendants or "parteras." After two years the program had prepared 768 parteras in a five-day training course. Parteras were equipped with a kit that included oral rehydration salts, an antihelminthic, multi-vitamins with iron, aspirin, contraceptives, and obstetrical equipment. The difficulties encountered in implementing this limited set of simple health services illustrate a number of potential obstacles to the achievement of universal, comprehensive primary health care in less developed countries. The most prominent difficulties involved elements of the health service delivery system itself: supervision, the collection and use of management information, training, partera selection, and logistics. The experience also provided examples of issues in the design of delivery systems that require specific applied research.

The Quality Assurance Project: introducing quality improvement to primary health care in less developed countries.

Persistently excessive morbidity and mortality rates in less developed countries (LDCs) served by primary health care systems suggest that the quality of services is inadequate. The PRICOR project, sponsored by the United States Agency for International Development, has designed and implemented methods for quality assessment and problem solving in LDC health systems. After developing comprehensive lists of essential activities and tasks, similar to practice parameters, for seven child survival interventions, PRICOR supported comprehensive quality assessment studies in twelve LDC countries. The studies, yielding over 6000 observations of health worker-client encounters, indicated highly prevalent, serious program deficiencies in areas including diagnosis, treatment, patient education and supervision. To facilitate corrective action, PRICOR assisted managers in conducting operations research to resolve priority problems revealed by the assessments. The recently initiated Quality Assurance Project is building on PRICOR techniques in designing and implementing sustainable continuous quality improvement programs for LDC health systems.

PIP: The PRICOR Project developed extensive lists of essential tasks and activities for the effective delivery of child survival interventions (PRICOR Thesaurus): case management of acute respiratory infection, malaria, and diarrhea; growth monitoring and promotion; maternal health; and child spacing. It later helped managers and researchers in the use of the Thesaurus to conduct comprehensive systems analyses of these interventions in Colombia, Costa Rica, Haiti, Niger, Indonesia, Pakistan, Peru, Philippine,s Senegal, Togo, Thailand, and Zaire. These analyses confirmed that researchers and program managers can indeed study service delivery through systematic review of health worker performance. Further this evaluation of primary health care (PHC) systems in 12 countries identified repeat program deficiencies. For example, counseling by health workers to clients was consistently weak. The tended to not explain to mothers proper home treatment, describe danger sings, or ask them to repeat instructions to assure that mothers understood them. Further health workers did not necessarily tell mothers during treatment about their child's nutritional status, type of vaccine being administered, of why they prescribed oral rehydration therapy. This lack of client education is especially significant since, in PHC, the health workers and the caregiver should be partners in achieving successful results. Deficiencies also existed with supervision. For instance, supervisors did not always monitor health workers, rectify errors, or solve problems. Further researchers compare supervisors' perceptions of health worker performance with actual performance. Supervisors tended to overstate performance. Nevertheless these analyses did identify practical solutions to many program deficiencies. In fact, most solutions did not depend on resources availability, PRICOR techniques to design and implement strategies for sustained improvement in PHC in developing countries.