Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal

Introduction

Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal.

Methods

Data were sourced from the Nepal Health Facility Survey 2015, which covered a national representative sample of health facilities. The datasets were analysed to assess service readiness, availability and quality of delivery and newborn care in a sample of 992 health facilities.

Results

Of the 992 facilities in the sample, 623 provided delivery and newborn care services. Of the 623 facilities offering delivery and newborn care services, 13.3% offered comprehensive emergency obstetric care (CEmONC), 19.6% provided basic emergency obstetric care (BEmONC) and 53.9% provided basic delivery and newborn service. The availability of essential equipment for delivery and newborn care was more than 80% in health facilities. Except for the coverage of vitamin K injection, the coverage of immediate newborn care was more than 85% in all health facilities. The coverage of use of chlorhexidine ointment to all newborns was more than 70% in government hospitals and primary health care centers (PHCCs) and only 32.3% in private hospitals.

Conclusions

These findings show gaps in equipment and drugs, especially in PHCCs and private health facilities. Improving readiness and availability of equipment and drugs in PHCCs and private health facility will help improve the quality of care to further reduce maternal and newborn mortality in Nepal.

     

分级诊疗制度实施中医院检验科如何提供区域检验服务的思考

随着我国分级诊疗制度的实施,三级医院检验科面临分级诊疗带来的挑战和机遇。理性评估检验科的优势、劣势、机会和威胁,积极响应国家政策的号召,适时调整学科发展的方向,集医学检验之优势资源,整合检验设备,发挥在医学服务、技术创新、质量管理和人才培养等方面的引领作用,积极探索并大力发展区域医学检验机构和尝试分级检验模式,服务基层群众,提升检验行业的公信力和竞争力;以拓展服务领域,开创良好的检验医学发展前景。     

新生儿重症监护室医院感染的监测与控制措施

目的：通过对新生儿重症监护室（NICU）医院感染状况的监测,探讨相关因素及积极有效的控制措施。方法：分析NICU 2301例新生儿的医院感染发生率,监测患儿感染的疾病、感染部位以及监护室内空气、医护人员的手卫生、医疗器械的消毒情况。结果：发生医院感染65例,79例次,感染率为2.82%,感染例次率为3.43%。胎龄小、体重低、住院时间长、抗生素的应用、医护人员的手卫生、NICU的环境和侵入性操作等均为医院感染的高危因素。结论：加强新生儿重症监护室医院感染的管理,针对感染高危因素采取有效的预防措施,可减少新生儿重症监护室医院感染的发生。     

Continuity of primary care and prenatal care adequacy among women with disabilities in Ontario: A population-based cohort study

BackgroundWomen with disabilities experience elevated risks for pregnancy complications and report barriers accessing prenatal care. Emerging evidence highlights the significant role primary care providers play in promoting preventive services like prenatal care.ObjectiveTo examine the relationship between continuity of primary care (COC) and prenatal care adequacy among women with disabilities.MethodsWe conducted a population-based study using health administrative data in Ontario, Canada. The study population included 15- to 49-year-old women with physical (n = 106,555), sensory (n = 32,194), intellectual/developmental (n = 1515), and multiple (n = 6543) disabilities who had a singleton livebirth or stillbirth in 2003–2017 and ≥ 3 primary care visits < 2 years before conception. COC was measured using the Usual Provider of Care Index. Nominal logistic regression was used to compute adjusted odds ratios (aOR) for prenatal care adequacy, measured using the Revised-Graduated Prenatal Care Utilization Index, for women with low versus moderate/high COC, controlling for other social and medical characteristics.ResultsWomen with disabilities with low COC, versus those with moderate/high COC, had increased odds of no (aOR 1.42, 95% CI 1.29–1.56), inadequate (aOR 1.19, 95% CI 1.16–1.23), and intensive prenatal care (aOR 1.22, 95% CI 1.19–1.25) versus adequate. In additional analyses, women with low COC and no/inadequate prenatal care were the most socially disadvantaged among the cohort, and those with low COC and intensive prenatal care had the greatest medical need.ConclusionImproving primary care access for women with disabilities, particularly those experiencing social disadvantage, could lead to better prenatal care access.     

Caring for children with specialized health care needs in the community: the challenges for primary care

People needing intensive and specialized health care are being cared for now in community settings; this has implications for both primary health care professionals and family carers. This paper draws on research investigating how services can be developed to support families caring for children with complex health care needs, to consider the challenges facing professionals working in the primary health care sector. Interviews conducted with parents, professionals and those who fund and commission specialized health services reveal particular problems in relation to the purchasing and provision of short-term care and specialist equipment/therapies in the community. These problems need to be addressed if people with specialized needs are to be cared for outside hospitals. The new Primary Care Groups (PCGs) will have the opportunity to enhance the provision of these services. Primary care professionals will also need to work in partnership with other sectors of the health service and with local authority services, at both strategic and operational levels, to develop integrated and coordinated services for this growing group of people.     

Impact of a Japanese Incentivization Program to Increase End-of-Life Care Outside of Hospitals

ObjectivesTo analyze the association of an incentivization program to promote death outside of hospitals with changes in place of death.DesignA longitudinal observational study using national databases.Setting and ParticipantsParticipants comprised Japanese decedents (≥65 years) who had used long-term care insurance services and died between April 2007 and March 2014.MethodsUsing a database of Japanese long-term care insurance service claims, subjects were divided into community-dwelling and residential aged care (RAC) facility groups. Based on national death records, change in place of death after the Japanese government initiated incentivization program was observed using logistic regression.ResultsHospital deaths decreased by 8.7% over time, mainly due to an increase in RAC facility deaths. The incentivization program was more associated with decreased in-hospital deaths for older adults in RAC facilities than community-dwelling older adults.Conclusions and ImplicationsIn Japan, the proportion of in-hospital deaths of frail older adults decreased since the health services system introduced the incentivization program for end-of-life care outside of hospitals. The shift of place of death from hospitals to different locations was more prominent among residents of RAC facilities, where informal care from laymen was required less, than among community residents.     

Community-Based Home Healthcare Project for Korean Older Adults

ObjectivesThe aim of this study was to identify the effects of community-based home healthcare projects that influence service performances with regard to Korean national long-term care insurance services in older adults.MethodsThe project's applicants were 18 operational agencies in national long-term care institutions in Korea, and participants were care recipients (n = 2263) registered in long-term care institutions. We applied our healthcare system to the recruited participants for a 3-month period from October 2012 to December 2012. We measured the community-based home healthcare services such as long-term care, health and medical service, and welfare and leisure service prior to and after applying the community-based home healthcare system.ResultsAfter the implementation of community-based home healthcare project, all community-based home healthcare services showed an increase than prior to the project implementation. The nutrition management service was the most increased and its increase rate was 628.6%. A comparison between the long-term care insurance beneficiaries and nonbeneficiaries showed that health and medical services’ increase rate of nonbeneficiaries was significantly higher than beneficiaries (p < 0.001).ConclusionOur community-based home healthcare project might improve the service implementation for older adults and there was a difference in the increase rate of health and medical services between Korean national long-term care insurance beneficiaries and nonbeneficiaries.     

重症监护病房新生儿护理的风险因素及预防措施

目的探讨重症监护病房新生儿护理的风险因素及预防措施。方法选取2013年5月至2014年5月我院施行NICU风险管理期间NICU收治的患儿共112例为观察组,选取2012年4月至2013年4月我院未施行NICU风险管理时NICU收治的患儿共131例为对照组,比较两组患儿NICU治疗过程中风险事件发生率。结果对照组和观察组患儿风险事件发生率分别为22.1%、7.1%,两组比较差异具有统计学意义(P<0.05)。结论 NICU护理风险因素主要包括新生儿自身因素、护理人员因素及医疗设备因素,加强风险管理可有效降低NICU护理风险,提高护理质量。     

Strengthening primary care: The Veneto Region’s model of the Integrated Medical Group

PurposeThis paper aims to illustrate the development of the Veneto Region’s (Italy) new primary care model and to report on the preliminary results.BackgroundAchieving integrated management and continuity of care are the two main aims of the Veneto Region’s health planning legislation for 2012-2016. Under this framework, and to meet new emerging population needs, it has become necessary to adopt a new primary care model that embraces multi-professional teams. In response the Veneto Region has developed the Integrated Medical Group (IMG), launched in 2016. The Integrated Medical Group is an innovative model at both the regional and national level and represents a key element of the health care system. It targets several goals: it provides more effective care than in the past; guarantees services within the region while optimizing the use of resources, through integrated patient care and its accompanying care pathways; it builds dialogue between hospitals and community based primary care services; develops relationships of trust between doctors and patients, pursuing shared team goals and enhances the different skills and roles of their constituent members.Regional legislation sets challenging objectives, stating that by the end 2017, 60% of all GPs in the region should conduct their activities as part of an IMG, with a further target of 80% by the end 2018.     

The effect of health care expenditure on patient outcomes: Evidence from English neonatal care

The relationship between health care expenditure and health outcomes has been the subject of recent academic inquiry in order to inform cost‐effectiveness thresholds for health technology assessment agencies. Previous studies in public health systems have relied upon data aggregated at the national or regional level; however, there remains debate about whether the supply side effect of changes to expenditure are identifiable using data at this level of aggregation. We use detailed patient data derived from electronic neonatal records across England along with routinely available cost data to estimate the effect of changes to patient expenditure on clinical health outcomes in a well‐defined patient population. A panel of 32 neonatal intensive care units for the period 2009–2013 was constructed. Accounting for the potential endogeneity of expenditure a £100 increase in the cost per intensive care cot day (sample average cost: £1,127) is estimated to reduce the risk of mortality of 0.38 percentage points (sample average mortality: 11.0%) in neonatal intensive care. This translates into a cost per life saved in neonatal intensive care of approximately £420,000.     

Primary care in the United States and its precarious future

Primary care has not secured a firm place within the US health services system. Since primary care lacks a strong research base, is not institutionalized in medical education or in policy-making and is marginalized in both proposed and actual reforms, it has not developed into a central component of the health care infrastructure. We discuss recent efforts that promised modest improvements, including the Clinton health care reform proposals and subsequent federal and state actions, in the role of primary care within the health services system. We also assess the likely fate of primary care given the accelerated growth of managed care and market competition, the dissatisfaction of large segments of the population with managed care and misperceptions of managed care as synonymous with primary care. We highlight how managed care fails to achieve the cardinal functions of primary care and summarize initiatives that, at a minimum, would be required to secure a stronger position for primary care in the future.     

Differences in readiness between rural hospitals and primary care providers for telemedicine adoption and implementation: findings from a statewide telemedicine survey

Purpose: Published advantages of and challenges with telemedicine led us to examine the scope of telemedicine adoption, implementation readiness, and barriers in a southern state where adoption has been historically low. We hypothesized that rural hospitals and primary care providers (RPCPs) differ on adoption, readiness, and implementation barriers. We examined the degree to which they differ on (a) telemedicine adoption or readiness; (b) telemedicine training needs; (c) current use of technology for patient care; and (d) environmental concerns in facilities for telemedicine. Methods: Paper surveys were sent to rural hospitals and RPCPs with response rates of 50% (n = 38) and 25.9% (n = 339), respectively. Three of 4 hospitals were represented. Chi‐square analyses were used to test for differences between rural hospitals and RPCPs. Findings: Compared to RPCPs, rural hospitals were significantly more likely to report higher rates of telemedicine knowledge (P= .0007); planning for or implementing telemedicine (P < .0001); and reporting their disaster recovery data systems (P= .0002) and availability and location of outlets and connections (P= .03) as adequate for telemedicine. Rural hospitals were less likely to report having no telemedicine education needs (P= .04). Conclusions: Telemedicine continues to be a viable solution for bridging geographic access gaps to a variety of specialty care. Users need assistance in understanding legal implications, care coordination, billing for services, and disaster data recovery. In rural areas, hospitals appear to best embody characteristics of facilities that successfully implement telemedicine and have the greatest degree of readiness.     

Large Independent Primary Care Medical Groups

PURPOSEIn the turbulent US health care environment, many primary care physicians seek hospital employment. Large physician-owned primary care groups are an alternative, but few physicians or policy makers realize that such groups exist. We wanted to describe these groups, their advantages, and their challenges.METHODSWe identified 21 groups and studied 5 that varied in size and location. We conducted interviews with group leaders, surveyed randomly selected group physicians, and interviewed external observers—leaders of a health plan, hospital, and specialty medical group that shared patients with the group. We triangulated responses from group leaders, group physicians, and external observers to identify key themes.RESULTSThe groups’ physicians work in small practices, with the group providing economies of scale necessary to develop laboratory and imaging services, health information technology, and quality improvement infrastructure. The groups differ in their size and the extent to which they engage in value-based contracting, though all are moving to increase the amount of financial risk they take for their quality and cost performance. Unlike hospital-employed and multispecialty groups, independent primary care groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Each group was positively regarded by external observers. The groups are under pressure, however, to sell to organizations that can provide capital for additional infrastructure to engage in value-based contracting, as well as provide substantial income to physicians from the sale.CONCLUSIONSLarge, independent primary care groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting.     

Improving Service Quality in Long-term Care Hospitals: National Evaluation on Long-term Care Hospitals and Employees Perception of Quality Dimensions

ObjectivesTo investigate predictors for specific dimensions of service quality perceived by hospital employees in long-term care hospitals.MethodsData collected from a survey of 298 hospital employees in 18 long-term care hospitals were analysed. Multivariate ordinary least squares regression analysis with hospital fixed effects was used to determine the predictors of service quality using respondents’ and organizational characteristics.ResultsThe most significant predictors of employee-perceived service quality were job satisfaction and degree of consent on national evaluation criteria. National evaluation results on long-term care hospitals and work environment also had positive effects on service quality.ConclusionThe findings of the study show that organizational characteristics are significant determinants of service quality in long-term care hospitals. Assessment of the extent to which hospitals address factors related to employee-perceived quality of services could be the first step in quality improvement activities. Results have implications for efforts to improve service quality in long-term care hospitals and designing more comprehensive national evaluation criteria.     

Availability, Utilisation and Quality of Basic and Comprehensive Emergency Obstetric Care Services in Malawi

Objective To establish a baseline for the availability, utilisation and quality of maternal and neonatal health care services for monitoring and evaluation of a maternal and neonatal morbidity/mortality reduction programme in three districts in the Central Region of Malawi. Methods Survey of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183). Results There were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23% of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7%. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0%. Up to 86.7% of pregnant women attended antenatal clinic at least once and only 12.0% of them attend postnatal clinic at least once. There is a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed. Conclusions The total number of CEmOC facilities is adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts. In order to reduce maternal mortality in Malawi and countries with similar socio-economic profile, there is a need to upgrade some health facilities to at least BEmOC level by training staff and providing equipment and supplies.     

农村地区县妇幼保健院助产服务现状及优势分析

目的:调查农村地区不同类别助产机构产科服务提供情况及服务能力,对县妇幼保健院助产服务现状和优势进行分析。方法:在全国随机抽取44个地市全部助产服务机构2010年产科服务情况进行问卷调查,重点对农村地区(县和县级市)中不同类型助产机构进行分析。结果:农村助产服务机构中县妇幼保健院占6.5%,县妇幼保健院产科床位数占辖区产科总床位数的18.1%,分娩数量占辖区分娩量的42.9%,平均每个县妇幼保健院年分娩为1 259人,高于县级综合性医院和其他医疗机构。县妇幼保健院中能提供综合产科和综合新生儿科服务的比例最高分别为85.3%、61.9%,高于县级综合性医院83.1%、59.4%,并明显高于其他医疗机构32.4%、19.3%。结论:县妇幼保健院是农村地区助产服务的主要力量之一,与其他助产机构相比,县妇幼保健院在助产服务提供数量和能力方面都具有一定优势。应进一步加强对妇幼保健机构的规范化建设,以保证其职能的履行。     

Health technology assessment in Belgium

The Belgian healthcare system has a Bismarck-type compulsory health insurance, covering almost the entire population, combined with private provision of care. Providers are public health services, independent pharmacists, independent ambulatory care professionals, and hospitals and geriatric care facilities. Healthcare responsibilities are shared between the national Ministries of Public Health and Social Affairs, and the Dutch-, French-, and German-speaking Community Ministries of Health. The national ministries are responsible for sickness and disability insurance, financing, determination of accreditation criteria for hospitals and heavy medical care units, and construction of new hospitals. The six sickness and disability insurance funds are responsible for reimbursing health service benefits and paying disability benefits. The system's strength is that care is highly accessible and responsive to patients. However, the healthcare system's size remained relatively uncontrolled until recently, there is an excess supply of certain types of care, and there is a large number of small hospitals. The national government created a legal framework to modernize the insurance system to control budgetary deficits. Measures for reducing healthcare expenditures include regulating healthcare supply, healthcare evaluation, medical practice organization, and hospital budgets. The need to control healthcare facilities and quality of care in hospitals led to formal procedures for opening hospitals, acquiring expensive medical equipment, and developing highly specialized services. Reforms in payment and regulation are being considered. Health technology assessment (HTA) has played little part in the reforms so far. Belgium has no formal national program for HTA. The future of HTA in Belgium depends on a changing perception by providers and policy makers that health care needs a stronger scientific base.     

NICU医院感染监测及护理对策

目的 了解新生儿重症监护病房医院感染的特点,为实施科学有效的干预措施提供依据.方法 2009年7月-2010年6月入住新生儿重症监护病房＞48 h的全部住院患儿1480例,进行医院感染前瞻性监测,对转出患儿随访48 h.结果 医院感染发生率为3.51％,其中主要感染为呼吸道感染占44.23％,其次为胃肠道感染占38.46％;呼吸机的利用率1.66％,呼吸机使用日的感染率为0.13‰.结论 加强新生儿医院感染的监测,严格执行感染控制措施,降低医院感染率.     

Dar es Salaam perinatal care study: needs assessment for quality of care

OBJECTIVE: Poor obstetric care in low income countries has been attributed to a wide range of factors. We conducted a perinatal care needs assessment in Dar es Salaam health institutions to assess the factors underlying the present poor perinatal outcome. METHODS: A cross sectional study was conducted in 2005 in all four public hospitals and all five public health centres purposively selected, and in six dispensaries selected using simple random sampling method. WHO Safe Motherhood needs assessment instruments were used to assess structural, systemic and process needs for quality perinatal care. Health care providers, administrators and clients were interviewed about perinatal care services in their respective health institutions. RESULTS: The majority (72%) of all deliveries in Dar es Salaam took place in the four available public hospitals. The potential coverage of comprehensive and basic emergency obstetric care (EmOC) services were 360% and 350% of the United Nations minimum recommended health institution categories per 500,000 population respectively. The coverage for health centres and dispensaries based on Tanzanian standards were 20% and 24% respectively. Two of the hospitals did not provide theatre and blood transfusion services for 24 hours per day. Two public health centres did not provide delivery services at all and 83% of the dispensaries had poorly established obstetric services. There was only one public neonatal unit that served as a referral institution for all sick newborns delivered in public health institutions in the region. CONCLUSION: This paper reveals the state of inadequate infrastructure, equipments and supplies for perinatal care in Dar es Salaam public health institutions. A major investment is needed to establish new public infrastructure for maternal and neonatal care, upgrade and optimize use of the existing ones, and improve supply of essential material resources in order to achieve the Millennium Development Goals set for maternal and child survivals by 2015.     

A cross-sectional assessment of primary healthcare facilities for provision of antenatal care: calling for improvements in Basic Health Units in Punjab,Pakistan

Background

There are two types of barriers to the utilisation of maternal health and antenatal care (ANC) services, including the supply-side barriers operating at the health facility level and demand-side, affecting the utilisation ANC services by pregnant women. The purpose of the study was to assess the essential resources required for the provision of ANC services in primary healthcare facilities in Punjab, Pakistan.

Methods

A cross-sectional facility assessment was conducted in primary healthcare facilities across Punjab. A multi-stage sampling was used to randomly select nine districts from three stratifications and 19 primary healthcare facilities in the public sector (17 Basic Health Units (BHUs) and two Rural Health Centres (RHCs)) from each district. A total of 171 health facilities were included. Data on infrastructure and availability of equipment, essential supplies, medicines, treatment protocols, and infection control items was collected through pre-tested, semi-structured questionnaires. Univariate analysis was carried out to describe the frequency and percentages of facilities across three ratings (good, average, and poor) by type of facility.

Results

Overall, 28% of facilities had poor infrastructure and the availability of equipment was poor in 16% of the health facilities. Essential supply items, such as urine strips for albumin, blood sugar testing strips, and haemoglobin reagents, were particularly poorly stocked. However, infrastructure and the availability of equipment and supplies were generally better in RHCs compared to BHUs.

Conclusion

Health facilities lacked the resources required to provide quality ANC services, particularly in terms of infrastructure, equipment, supply items, and medicines. The availability of these resources needs to be urgently addressed.