Improving the quality of hospital care for children by supportive supervision: a cluster randomized trial, Kyrgyzstan.

OBJECTIVE: To determine whether periodic supportive supervision after a training course improved the quality of paediatric hospital care in Kyrgyzstan, where inappropriate care was common but in-hospital postnatal mortality was low. METHODS: In a cluster, randomized, parallel-group trial, 10 public hospitals were allocated to a 4-day World Health Organization (WHO) course on hospital care for children followed by periodic supportive supervision by paediatricians for 1 year, while 10 hospitals had no intervention. We assessed prospectively 10 key indicators of inappropriate paediatric case management, as indicated by WHO guidelines. The primary indicator was the combination of the three indicators: unnecessary hospitalization, increased iatrogenic risk and unnecessary painful procedures. An independent team evaluated the overall quality of care. FINDINGS: We prospectively reviewed the medical records of 4626 hospitalized children aged 2 to 60 months. In the intervention hospitals, the mean proportion of the primary indicator decreased from 46.9% (95% confidence interval, CI: 24.2 to 68.9) at baseline to 6.8% (95% CI: 1.1 to 12.1) at 1 year, but was unchanged in the control group (45.5%, 95% CI: 25.2 to 67.9, to 64.7%, 95% CI: 43.3 to 86.1). At 1 year, the risk ratio for the primary indicator in the intervention versus the control group was 0.09 (95% CI: 0.06 to 0.13). The proportions of the other nine indicators also decreased in the intervention group (P < 0.0001 for all). Overall quality of care improved significantly in intervention hospitals. CONCLUSION: Periodic supportive supervision for 1 year after a training course improved both adherence to WHO guidelines on hospital care for children and the overall quality of paediatric care.

Child and adolescent health in Europe: Towards meeting the 2030 agenda.

Background: Childhood and adolescence are critical stages for a healthy life. To support countries in promoting health and development and improving health care for this age group, the WHO Regional Office for Europe developed the European strategy for child and adolescent health 2015-2020, which was adopted by all countries. This paper reports progress in the strategy's implementation until 2020. Methods: A survey was sent to all ministries of health of the 53 Member States of the WHO European Region. Responses were received from 45 Member States. Results are presented in this paper. Results: The European Region made overall progress in recent years, but increasing levels of overweight and obesity among children, adolescent mental health and low breastfeeding rates are recognized as key national challenges. Although forty-one countries adopted a national child and adolescent health strategy, only eight countries involve children in their review, development and implementation stages. Two-thirds of countries have a strategy for health-promoting schools and a school curriculum for health education. One-third of countries do not have legislation against marketing of unhealthy foods and beverages to children. Most countries reported routine assessment for developmental difficulties in children, but less than a quarter collected and reported data on children who are developmentally on track. There are major gaps in data collection for migrant children. Hospitalization rates for young children vary five-fold across the region, indicating over-hospitalization and access problems in some countries. Only ten countries allow minors access to health care without parental consent based on their maturity and only eleven countries allow school nurses to dispense contraceptives to adolescents without a doctor's prescription. Conclusions: This paper shows the progress in child and adolescent health made by countries in Europe until 2020 and key areas where additional work is needed to move the 2030 agenda forward. The survey was undertaken before the COVID-19 pandemic and the war in Ukraine. Both will likely exacerbate many of the observed problems and potentially reverse some gains reported. A renewed commitment is needed.

The integrated management of childhood illness (IMCI) and its potential to reduce the misuse of antibiotics.

BACKGROUND: The Strategy of the Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, the misuse of antibiotics, polypharmacy and over-hospitalization of children. A study carried out in 16 countries analysed the status and strengths of as well as the barriers to IMCI implementation and investigated how different health systems affect the problems IMCI aims to address. Here we present findings in relation to IMCI's effects on the rational use of drugs, particularly the improved rational use of antibiotics in children, the mechanisms through which these were achieved as well as counteracting system factors. METHODS: 220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data was analysed for arising themes and peer-reviewed. RESULTS: The implementation of IMCI led to improved prescribing patterns immediately after training of health workers according to key informants. IMCI provides standard treatment guidelines and an algorithmic diagnostic- and treatment-decision-tool for consistent decision-making. Doctors reported feeling empowered by the training to counsel parents and address their expectations and desire for invasive treatments and the use of multiple drugs. Improved prescribing patterns were not sustained over time but counteracted by factors such as: doctors prescribing antibiotics to create additional revenues or other benefits; aggressive marketing by pharmaceutical companies; parents pressuring doctors to prescribe antibiotics; and access to drugs without prescriptions. CONCLUSIONS: Future efforts to improve child health outcomes must include: (1) the continued support to improve health worker performance to enable them to adhere to evidence-based treatment guidelines, (2) patient and parent education, (3) improved reimbursement schemes and prescription regulations and their consistent enforcement and (4) the integration of point-of-care tests differentiating between viral and bacterial infection into standards of care. Pre-requisites will be sufficient remuneration of health workers, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care.

Review of Integrated Management of Childhood Illness (IMCI) in 16 countries in Central Asia and Europe: implications for primary healthcare in the era of universal health coverage.

The Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, antibiotics misuse, polypharmacy and overhospitalisation. This study in 16 countries analyses status, strengths of and barriers to IMCI implementation and investigates how health systems affect the problems IMCI aims to address. 220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data were analysed for arising themes and peer-reviewed. IMCI has not been fully used either as a strategy or as an algorithmic diagnostic and treatment decision tool. Inherent incentives include: economic factors taking precedence over evidence and the best interest of the child in treatment decisions; financing mechanisms and payment schemes incentivising unnecessary or prolonged hospitalisation; prescription of drugs other than IMCI drugs for revenue generation or because believed superior by doctors or parents; parents' perception that the quality of care at the primary healthcare level is poor; preference for invasive treatment and medicalised care. Despite the long-standing recognition that supportive health systems are a requirement for IMCI implementation, efforts to address health system barriers have been limited. Making healthcare truly universal for children will require a shift towards health systems designed around and for children and away from systems centred on providers' needs and parents' expectations. Prerequisites will be sufficient remuneration, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care.

Child and adolescent health in Europe: monitoring implementation of policies and provision of services.

To promote children's health in Europe, the WHO Regional Office for Europe developed a strategy for child and adolescent health for the period 2015-20, which was adopted by all 53 European member states. The priorities of the strategy are broad and include action around supporting early childhood development, reducing exposure to violence, and tackling mental health problems in adolescence. The strategy's implementation was monitored with a survey of 82 questions sent to the ministries of health in all member states in 2016. Responses were received from 48 countries (91% of the region). Encouragingly, three-quarters of countries have either adopted or plan to develop a national child and adolescent health strategy. However, variation exists in the adoption of key components of the regional strategy and in the collection of data. For example, access to sexual and reproductive health services is unequal across the region, and childhood obesity and mental health are key areas of concern. Such survey data helps member states and the general public review achievements and address obstacles for children and adolescents realising their full potential for health, development, and wellbeing. The survey will be repeated in 2019 to identify subsequent changes in child and adolescent health in countries across Europe.

Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on.

OBJECTIVE: To assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries. SETTING: The 95 countries that participated in the survey are home to 82% of the global under-five population and account for 95% of the 5.9 million deaths that occurred among children less than 5 years of age in 2015; 93 of them are low-income and middle-income countries (LMICs). METHODS: We conducted a cross-sectional self-administered survey. Questionnaires and data analysis focused on (1) giving a general overview of current organisation and financing of IMCI at country level, (2) describing implementation of IMCI's three original components and (3) reporting on innovations, barriers and opportunities for expanding access to care for children. A single data file was created using all information collected. Analysis was performed using STATA V.11. PARTICIPANTS: In-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef. RESULTS: Eighty-one per cent of countries reported that IMCI implementation encompassed all three components. Almost half (46%; 44 countries) reported implementation in 90% or more districts as well as all three components in place (full implementation). These full-implementer countries were 3.6 (95% CI 1.5 to 8.9) times more likely to achieve Millennium Development Goal 4 than other (not full implementer) countries. Despite these high reported implementation rates, the strategy is not reaching the children who need it most, as implementation is lowest in high mortality countries (39%; 7/18). CONCLUSION: This survey provides a unique opportunity to better understand how implementation of IMCI has evolved in the 20 years since its inception. Results can be used to assist in formulating strategies, policies and activities to support improvements in the health and survival of children and to help achieve the health-related, post-2015 Sustainable Development Goals.

Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment.

BACKGROUND: Major concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States. METHODS: We assessed 17 hospitals in Kazakhstan, the Republic of Moldova, and the Russian Federation with a generic WHO hospital assessment framework adapted for use in the WHO European region. WHO management guidelines for paediatric care in peripheral hospitals were used as standards. FINDINGS: Hospital access for children was generally good. Good health networks existed, and skilled and committed doctors cared for children. Case-fatality rates were low. However, unnecessary and lengthy hospital stays were common, and most children received excessive and ineffective treatment (in one country median number of drugs prescribed concurrently was 5, IQR 2-6). Several conditions were systematically overdiagnosed, especially neurological disease, or overinvestigated, such as acute diarrhoea. Reasons for these practices included absence of clear evidence-based clinical guidelines, regulations tying duration of admission to financial reimbursement, generalisation of disease-control methods from rare problems to common illnesses, and regulations maintaining financial and professional status of some subspecialties. Many disincentives to efficient practice existed. INTERPRETATION: To improve quality of hospital care for children in the Commonwealth of Independent States, several issues must be addressed, including: adoption of international guidelines for inpatient management; complementary guidelines for outpatient management; reforms to health regulations governing admission and discharge criteria; improvement of quality of training, availability of medical information, and systems to promote and certify quality of care.

Assessing and Improving Children's Rights in Hospitals: Case Studies from Kyrgyzstan, Tajikistan, and Moldova.

There is a recognized need to raise evidence on how to adopt human rights-based approaches (HRBAs) to health and to assess their impact. In 2013 and 2014, the World Health Organization (WHO) Regional Office for Europe used a set of tools to assess and improve the situation of children's rights in 11 hospitals in Kyrgyzstan, 10 hospitals in Tajikistan, and 21 hospitals in Moldova, by applying a HRBA to health, taking as a reference the Convention on the Rights of the Child (CRC). The assessment results show a similar situation across countries in some areas, and more or less significant variation in others. Common gaps include the need to improve adolescent-friendly health services, the rights to privacy and play; and infrastructure and equipment. In Kyrgyzstan and Tajikistan, a second round of assessment, was carried out, which showed an effective change in several areas, whilst other areas showed persistent gaps. Moldova did not carry out a second round of assessment. Involving children and parents in the assessment was crucial to obtain more reliable data; the project showed how to use the CRC as a framework to improve quality of care for children (QoC); and the tools were proven useful for self-assessment.