Global Initiatives for Improving Hospital Care for Children: State of the Art and Future Prospects
Deficiencies in the quality of health care are major limiting factors to the achievement of the Millennium Development Goals for child and maternal health. Quality of patient care in hospitals is firmly on the agendas of Western countries but has been slower to gain traction in developing countries, despite evidence that there is substantial scope for improvement, that hospitals have a major role in child survival, and that inequities in quality may be as important as inequities in access. There is now substantial global experience of strategies and interventions that improve the quality of care for children in hospitals with limited resources. The World Health Organization has developed a toolkit that contains adaptable instruments, including a framework for quality improvement, evidence-based clinical guidelines in the form of the Pocket Book of Hospital Care for Children, teaching material, assessment, and mortality audit tools. These tools have been field-tested by doctors, nurses, and other child health workers in many developing countries. This collective experience was brought together in a global World Health Organization meeting in Bali in 2007. This article describes how many countries are achieving improvements in quality of pediatric care, despite limited resources and other major obstacles, and how the evidence has progressed in recent years from documenting the nature and scope of the problems to describing the effectiveness of innovative interventions. The challenges remain to bring these and other strategies to scale and to support research into their use, impact, and sustainability in different environments.
Most systems of health service delivery assume that people who become sick will first go to a primary care provider. From there the severely ill will be identified and referred onward for care that cannot be provided at an outpatient level. The World Health Organization (WHO)/United Nations Children's Fund (UNICEF) Integrated Management of Childhood Illness (IMCI) strategy seeks to strengthen prevention and care for children through appropriate community and household care, primary care, referral practices, and care at the first-level hospital. On the basis of current guidelines, it has been estimated that 10% to 20% of sick children who present for primary care (ie, the most severely ill) may require referral to a first referral or district hospital. The quality of care provided in these hospitals is likely therefore to have a major impact on the health and lives of millions of children each year.1 Unfortunately, there is good evidence that hospital care is often deficient in many countries, including a study of 21 hospitals across 7 countries in Asia and Africa.2 This study showed that more than half of the children were undertreated or inappropriately treated with antibiotics, fluids, feeding, or oxygen. Lack of triage and inadequate assessment, late treatment, inadequate drug supplies, poor knowledge of treatment guidelines, and insufficient monitoring of sick children were key adverse factors observed. Similar observations were made in a study in Kenya, with clear indications that most practitioners neither were aware of nor followed international guidance on best practice,3,4 and by assessments conducted in Brazil and Angola, where severe malnutrition and triage and emergency care were identified as priority areas to be addressed to decrease hospital mortality.5,6 Hospital assessment exercises supported by WHO in the past few years have found similar deficiencies in countries including Cambodia, Indonesia, Kazakhstan, Solomon Islands, and Timor Leste (www.who.int/child-adolescent-health/publications/OVERVIEW/ISBN_92_4_159223_0.htm). Despite this evidence, improving hospital care for children has not received much attention so far within the package of interventions to improve child survival.
This article reports current experience shared at a WHO-initiated global meeting in Bali in early 2007 of attempts to improve hospital care for newborns and children in low-income countries (www.who.int/child-adolescent-health). Clear progress has been made since an initial meeting in 2000 (www.who.int/child-adolescent-health/publications/pubCNH.htm) with the focus shifting from describing the scale of the problem to examining experiences with interventions. We present currently available generic tools and resources that can be locally adapted, highlight some selected country experiences in improving quality of hospital care, and discuss current challenges and future prospects.
AVAILABLE TOOLS AND STRATEGIES
Arising from locally identified needs in a number of countries, materials to support quality improvement (QI) have been developed and tested. The scale of these initiatives ranges from pilot projects to large programs with national coverage. The following is a brief description of several of these initiatives (with links on how to access additional details and/or copies of materials given in Table 1).
Pocket Book of Hospital Care for Children
This pocket-sized manual presents up-to-date clinical guidance for the inpatient treatment of the major causes of childhood mortality, such as pneumonia, diarrhea, severe malnutrition, malaria, meningitis, measles, HIV infection, neonatal problems, and surgical conditions. The recommendations are based on a review of the available published evidence by subject experts, and more than 130 pediatricians throughout the world contributed. The Pocket Book of Hospital Care for Children is designed for use by doctors, senior nurses, and other senior health workers who are responsible for the care of young children at the first referral level in developing countries and can provide the starting point for developing national clinical standards of care. It is currently available in approximately 20 languages, including English, French, Portuguese, Russian, and Chinese. The recommendations are designed for small hospitals where basic laboratory facilities and essential drugs and inexpensive medicines are available. A related publication, “Serious Childhood Problems in Countries With Limited Resources,”7 summarizes the technical background underlying these clinical guidelines. Recently, the International Child Health Review Collaboration (ICHRC) has been established to develop and make widely available summaries of systematic reviews of the evidence behind recommended practices and to ensure updating of the Pocket Book of Hospital Care for Children.8 Materials can be accessed on the ICHRC Web site (see Table 1).
Introduction Course to the Pocket Book of Hospital Care for Children
This training resource was developed to teach health workers how to make the best use of the Pocket Book of Hospital Care for Children in everyday clinical practice. A training CD-ROM contains clinical case–based teaching on each of the chapters focusing on all of the stages of care: triage, emergency treatment, diagnosis and differential diagnoses, treatment, monitoring and supportive care, discharge planning, and follow-up. In addition, for each chapter, the CD has video footage and clinical photographs illustrating important clinical syndromes and signs mentioned in the Pocket Book of Hospital Care for Children, plus other clinical resources such as monitoring charts. The CD is designed to be used either in a 4-day workshop to introduce the Pocket Book of Hospital Care for Children and train health workers in its use or in undergraduate or postgraduate courses, for self-learning or distance learning programs. The training CD-ROM is available in English, Russian, and a draft in Chinese.
Training Courses for Emergency Triage Assessment and Treatment (ETAT) and in Management of Severe Malnutrition
It is recognized that clinical guidelines need to be supported by training courses, especially for acquisition of skills, and that training should be accompanied by appropriate staff support and general improvements in service quality. Training is not an end in itself but needs to be embedded into a QI approach to lead to lasting effects. Because triage and emergency care were found to be deficient in several assessments, a 3.5-day ETAT course was developed, based on the Advanced Pediatric Life Support course but modified for use where human resources and laboratory backup are scarce. It follows the airway, breathing, circulation, disability (ABCD) approach of life support courses and has been validated against Advanced Pediatric Life Support.9 The training manual includes charts and tables that can be enlarged to use as wall charts in the workplace. They are available in English and French.
The management of severe malnutrition has been found to be very deficient in practically all countries where this has been studied.10 A 5-day training course has been developed in which participants are introduced to the 10 steps in management, focusing on principles such as correct preparation of and feeding with special formula diets, first a lower calorie content in the stabilization phase, and then a higher calorie feed in the rehabilitation phase.
Assessment Tool for Hospital Care for Children
In many countries, formal hospital assessments have been conducted to understand the fundamental problems and priorities in hospital care for children.2,5,6,11 For evaluation of the performance of hospitals, a structured assessment tool has been developed covering the most important aspects of pediatric hospital care in resource-poor countries.12 Standards for each condition are provided, and criteria to assess performance against these standards are defined. A scoring system grades the need for improvement in various areas. Data are collected through observations of areas where children are cared for; direct observation of the management of clinical cases; review of medical charts; and discussions with clinical staff, administrators, and parents. An example of a page is depicted in Fig 1. A structured action planning tool is provided to guide discussions with hospital authorities and to encourage a focus on the most urgent needs to improve hospital care. The tool has been adapted in each country where it has been used.
Framework for QI
WHO has developed a framework that outlines a sequence of steps and activities to address improving the quality of hospital care for children. Quality may be defined as adhering to expected standards, both those that are officially stated (as in national or local standards) and those that may be more implicitly held (eg, reflecting the expectations that parents may have about how staff at a health facility should treat their child). In pediatric care, such standards exist to ensure that children receive appropriate care; to avoid harmful practices; and to provide a benchmark for professional development, self-monitoring, and accreditation. The framework may be used at a national, regional, or hospital level. To start the process, a limited initial hospital assessment process is suggested. Assessment findings are then discussed by all stakeholders to promote broad participation in and ownership of the process. The importance of local leadership is emphasized. In many countries, progress will require the development or updating of national (or local) standards. Standards will be in the areas of treatment guidelines, essential medicines, technology and equipment, physical facilities, and human resources. A process to achieve such standards is outlined. Once these standards are in place, actions to improve quality in line with these standards should follow the steps in the QI cycle (Fig 2), including evaluation of progress. National programs should additionally, where possible, include efforts to go to scale to reach national coverage.
Manual of QI
During QI exercises in countries where participants were introduced to QI methods, a need for having a reference guide briefly describing the relevant processes, tools, and approaches became apparent. The manual is in draft for field-testing; it outlines how the tools may be used in settings where children and adolescents are cared for. Because a large part of the work consists of group work, selected facilitation techniques are included. The manual can be used as a reference for teaching and learning in QI methods or in a health facility that is undertaking QI activities.
EXAMPLES OF EXPERIENCES WITH QI INITIATIVES IN COUNTRIES WITH LIMITED RESOURCES
Malawi: Hospital QI Projects and Integrated Care Pathways
The Child Lung Health Project, coordinated by the International Union Against TB and Lung Diseases in collaboration with the Ministry of Health (MOH; www.iuatld.org/full_picture/en/about/divisions/division_child_lung_health.phtml), aimed to improve case management of childhood pneumonia in hospital and address specific resource barriers. The project included improving drug and consumable supplies and providing oxygen concentrators with regular maintenance for exclusive use in the pediatric wards of district hospitals and appropriate staff training. The intervention successfully encouraged staff to set up a separate “high dependency” room or area within the pediatric ward where oxygen could be provided for severely ill children. Long-term evaluation suggested significant improvements in quality of pneumonia care and a reduced case fatality ratio.13
The pediatric department of the College of Medicine in Blantyre, Malawi, has implemented critical care pathways (CCPs; also known as integrated care pathways14) to address the problem of often disorganized and illegible clinical notes.15 A CCP is a clinical record that documents on 1 chart the medications given, nursing and medical findings, patient monitoring details, and laboratory results. It incorporates times and actions so that the CCP is not only a record of care but also a guide to management and is used by all members of staff in the outpatient and the inpatient unit. Generic CCPs for pediatric medical admissions and neonates and 1 for severely malnourished children were developed, and these have strengthened teamwork in the pediatric unit and helped to increase the efficiency with which resources are deployed. They also provided an opportunity to note actions and progress in improving quality of care.15 Copies of these are available electronically and can be modified to ensure local relevance and ownership.
In the same department, a program of staff training in ETAT was incorporated within a program of general improvements to emergency services. This program started with a detailed analysis of deficiencies and led to improved patient flow through the emergency department, improved cooperation between inpatient and outpatient services, and improved staffing for better supervision. These changes were accompanied by a 40% reduction in inpatient mortality over 2 years.16
Solomon Islands: National QI Program
In the Solomon Islands, a country recovering from a civil conflict that seriously affected the child health service, innovative measures have been introduced to improve hospital care. In 2002, the results of an assessment of quality of care in provincial hospitals were presented to the MOH. The assessment highlighted several problems in clinical care, human resources, health financing, referral systems, and training. A training package was developed to introduce standard treatment guidelines based on the WHO materials. A 4-day course was held first for 25 nurses, representing child health workers from each of the 9 provinces, to provide a system of standardized management for serious and common childhood illnesses that can be used in isolated environments. In 2005–2007, this training strategy was extended to provinces, and the Pocket Book of Hospital Care for Children is now used throughout the country. Other parallel initiatives, including the development of a comprehensive National Child Health Plan and a system of child mortality reporting, have ensured that hospital QI is an integrated part of the child health program and that data are available for evaluation and policy development.17
Niger: Collaborative Networking of QI Programs
The Quality Assurance Project supports several countries in sub-Saharan Africa and Central America through the Pediatric Hospital Improvement Initiative (PHI). One example is Niger, where a collaborative network approach to QI has been initiated (www.qaproject.org/world/worldafrica.html#Niger). Initially, 14 hospitals and 3 referral maternities participated in the PHI collaborative. A baseline assessment in 2003 showed in-hospital pediatric case fatality ratio of 25% and a clear need identified for improvement in case management. On the basis of clearly defined norms, QI teams mapped out the care process, worked together to develop and implement solutions to problems, measured process, and defined outcome indicators. Collaborative sites were given training and support through visits from staff with expertise in both pediatric hospital care and QI. Best practices were shared in a national PHI conference. At this stage, an additional 15 sites were added, with coverage of all national hospitals and half of the district hospitals. To facilitate follow-up, support, and integration of the collaborative process into the Ministry of Health (MOH) structures, the collaborative process was decentralized. Learning sessions are organized and held at the regional level, and regional coaches have been trained to support the QI teams at the 32 sites. Achievements include substantial reductions in hospital case fatality ratios in the first 24 hours (Stephen Kinoti, MBChB, MMed, unpublished findings reported at Bali meeting, 2007).
South Africa and Papua New Guinea: Mortality Audit
There are many possible “entry points” when considering how to initiate, focus, and sustain improvement of hospital care. In South Africa and Papua New Guinea, systematic mortality review has been used. The Child Healthcare Problem Identification Program (www.chip.org.za) in South Africa provides structured computer-based tools for careful review of in-hospital deaths with the capacity to summarize, in automated analyses and reports, accumulating experience over time.18 Using the information derived from these mortality reviews, interventions at local, provincial, and national levels have led to measurable improvements in quality of care, including increasing the availability and uptake of maternal-to-child transmission prevention interventions and providing treatment for HIV-infected mothers and infants. The Child Healthcare Problem Identification Program may be easily generalizable to other countries with minor modifications. In Papua New Guinea mortality audit has enabled a better understanding of the complex social, epidemiologic, and health system factors surrounding child deaths.19–21 Mortality audit has contributed to identification of the need for better oxygen systems, identification of a major measles epidemic, advocacy for the introduction of the Haemophilus influenzae type b vaccine, and improved staffing in emergency and children's outpatient departments.
Commonwealth of Independent States Countries: Assessment of Hospital Care
In 2002, the WHO Regional Office for Europe promoted an assessment of the quality of hospital care for children. A sample of 17 hospitals was assessed in Kazakhstan, the Republic of Moldova, and the Russian Federation, using an adapted version of the WHO hospital assessment tool. Although the overall situation, characterized by a well-developed health system and relatively low case fatality rates, is not comparable to developing countries, several critical areas were identified: unnecessary and lengthy hospital stays; overdiagnosis particularly of neurologic conditions; and excessive, expensive, and ineffective treatment given to most children.11 These findings prompted WHO to convene a meeting among leading pediatricians and child neurologists from Commonwealth of Independent States countries. Participants from 12 countries recognized the need to revise definitions and clinical guidelines of the most common neurologic conditions, removing the obstacles to evidence-based practice and improving the training of pediatric staff. Other reforms and activities have also followed the assessment, including adaptation and implementation of the Pocket Book of Hospital Care for Children in Kazakhstan, Uzbekistan, and Turkmenistan.
CHALLENGES AND PROSPECTS
Until recently, relatively little international attention was paid to the issue of hospital care for children, perhaps because many children in developing countries die before reaching hospital or because of concern that promoting improved quality of hospital care might divert resources from primary care, but if hospitals are perceived as expensive places to die, where there is little prospect of effective treatment and little hope that a child will be cured, then why should parents follow referral advice? In Uganda, referral of children to district hospitals was often not completed because of both immediate financial constraints and beliefs by parents that hospital staff would treat their children poorly or that the hospitals lacked the necessary facilities and drugs.22 Improving quality of hospital care is therefore required to ensure that the majority of severely ill newborn infants and children get appropriate, effective, and timely treatment; to provide essential support to primary care facilities; and to provide an incentive for appropriate care seeking. In short, it is an essential component of an approach to strengthen the entire health care system and to achieve equity, because inequities in quality may be as important to global child mortality as inequities in access. It should therefore be part of the package of interventions used to achieve Millennium Development Goal 4, which aims to reduce child and newborn mortality, and, recognizing clear parallels with efforts to make pregnancy safer, Millennium Development Goal 5, which aims to reduce maternal mortality.
We recognize that weak infrastructure, shortage of essential supplies, and, most of all, the human resource crisis among health staff, especially in sub-Saharan Africa,23 are major limiting factors to quality care for children in developing countries. Reasons for slower progress in quality assurance in developing countries also include the lack of access to information (especially online information), the limited adaptation of QI strategies to developing country needs, and the misperception that a focus on patient quality and safety is expensive. Nevertheless, many of the approaches described in this review show that important advances can be made, although a number of key challenges have to be faced.
Building a QI culture is the priority challenge. QI should not be seen as a high-level activity that can be conducted only by QI staff. It is important that in practice this is seen as health workers' identifying problems, developing solutions, and testing them to determine whether they work before building them into health systems. To achieve this, QI principles should be incorporated into teaching hospital care so that medical students, interns, and nurses are exposed to models of good medical practice that will set patterns for a lifetime of work. This can be complemented by continuous, in-service education and training programs to introduce in everyday practice tools and methods of QI. Furthermore, improving quality should be seen as a cross-cutting, system-level intervention. This diverges from the still prominent vertical program approach with the danger that even at the hospital level, well-resourced programs (typically HIV, malaria, tuberculosis, and family planning) all develop independent parallel systems to address problems with “their” programs. Although these cross-cutting, system-level approaches will incur start-up costs, they may prove to be very cost-effective in the long run. Additional roles for teaching institutions include effective local development and adaptation of clinical guidelines based on evidence, perhaps through greater capacity development and involvement in initiatives such as the ICHRC,8 and through partnerships with established centers that could offer funding, training, and mentorship.
Going to scale is essential to achieving significant results. To do this, it will be important to tailor approaches to local circumstances. Standard tools and materials described in this article can act as a starting point, but a process of adaptation, implementation, monitoring, and revision will need to take place within health systems that are geared toward a sector-wide approach to improve hospital care. QI programs in maternal and child care at the hospital level could represent the vanguard of this wider effort. Because improved quality in hospital care can have a direct and measurable impact on key health indicators outlined in Millennium Development Goals 4 and 5, such as maternal and child mortality, the international pediatric community should play a leading role in advocating for and directly contributing to efforts to strengthen investments and develop innovative strategies in this area.
The Baby Friendly Hospital Initiative is a good example of a relatively simple accreditation system that has been widely implemented in developed as well as developing countries and has greatly contributed to improve quality of care in maternity units.24,25 This kind of approach could be expanded to cover hospital care for children more broadly; however, the Baby Friendly Hospital Initiative experience also serves as a reminder of the difficulties in sustaining an approach. Accreditation needs to be time limited and to provide an incentive to maintain improved levels of quality.
MOH first need to review current policies, standards, and programs that rely on or contribute to hospital care and develop a list of stakeholders (and possibly donors) who need to be involved. They need to identify who will coordinate activities for the MOH across sectors such as government, faith-based organizations, and relevant private agencies. Information gathering to help define local and national problems and priorities should be conducted through surveys that assess the quality of pediatric care in a sample of hospitals throughout the country. A meeting of stakeholders, including senior government pediatricians, educational institution representatives, child health nurses, rural representatives, and administrators would then develop consensus on these priorities and the ways forward. Key aspects of this would be setting of goals that are achievable (and affordable) and will promote equity, securing commitment to funding, and a commitment to evaluation of program performance against agreed goals. Training institutions should be included as an essential element of these programs so that students are aware of the standards, have problem-solving skills, and understand their role in ensuring that standards are adhered to.
Country-level programs would address each of the 9 factors outlined in Fig 3 in ways that are relevant to the particular country. These would include the following:
Introduction of the WHO Pocket Book of Hospital Care for Children (or, where it exists, improving existing clinical guidelines) as the national standard treatment, with adaptation, translation, training workshops, and incorporation into undergraduate and postgraduate courses.
Addressing other areas that are crucial to quality, including drug supplies, equipment issues and other supportive technology (eg, oxygen systems), human resources, health financing, physical facilities, and infrastructure. The program would be integrated with the other activities that occur in these areas. The program would also integrate with broader child health programs within the country and be able to address quality across various levels of the health service, the interaction with the community, and various demand issues.
Partnership between the national pediatric association and the MOH (program leaders will differ across countries, but, in most cases, such partnerships will be appropriate).
MOH may form a quality and safety committee within the curative services divisions. A clinician (probably a nurse) from each hospital would be funded as a pediatric quality and safety representative. This person would coordinate activities in that hospital, including training on clinical guidelines and addressing each of the deficiencies found in the assessment. Annual activity plans would be submitted by each hospital to the MOH for funding through this program. There would be an evaluation framework that would assist hospitals and countries with monitoring progress and impact of various strategies. Such information would be shared between countries in regional meetings held every 2 years.
In research, efforts are needed to identify the most effective and cost-efficient strategies and approaches to improve quality. This should be participatory “operational research” to maintain the relevance of results to real-life circumstances. The relative contribution to improved quality of pediatric hospital care of interventions that have been described in this article, such as the introduction of structured medical charts, internal audits, performance-based accreditation systems, computer-assisted mortality monitoring systems, and other approaches, must be assessed with rigorous methodologic approaches in different settings, also exploring the feasibility and effectiveness of various combinations. Contrary to some perceptions, a focus on quality and safety can save money with research on IMCI implementation and on introduction of improved oxygen delivery devices, demonstrating clear cost savings26,27; however, there often has to be an initial modest investment to save money in the longer term, and costing studies must take this into account. This type of implementation research has been undervalued and underresourced in the past, but there is now increasing international recognition of its importance.28–30 It is important that future research and implementation include an assessment of monetary costs and savings linked to QI processes.
Recent developments and the new commitments of several key actors are encouraging. Besides the recent WHO initiative in Indonesia, several nongovernmental organizations and bilateral government agencies are supporting QI programs in perinatal and child health. The International Pediatric Association has identified quality of care as a priority area and is proposing regional workshops to introduce the available tools and methods to pediatricians through their national or subspecialty societies. Professional organizations can play a crucial role in improving quality of care, particularly at the hospital level. Cooperation among them and national health authorities, international agencies, and nongovernmental organizations is essential to achieve results. The efforts parallel recent initiatives in industrialized countries to introduce QI programs into national programs.31–33
There is now a wealth of experience in many countries with approaches to improve quality of hospital care for children. Materials have been developed to support these programs, and there are an increasing number of health professionals who have experience in putting this theory into practice. It is now our challenge to implement and scale up these approaches to achieve national coverage and make them sustainable.
We acknowledge the contributions of the medical, nursing, and administrative staff in the institutions of the following groups of the Pediatric Hospital Improvement Group for contributions to the developments of the ideas and initiatives described in this report: Trevor Duke, Australia; Sophie La Vincente, Australia; Rami E. Subhi, Australia; Mohammed Nurul Alam, Bangladesh; Dewan Md. Emdadul Hoque, Bangladesh; Shafiqul Islam, Bangladesh; Lorn Try Patrich, Cambodia; Ung Sophal, Cambodia; Hong Rathmony, Cambodia; Tsegereda Gebrehiwot, Eritrea; Penny Enarson, France; Andreas Hansmann, Germany; Sandeep Kumar Kanwal, India; Waldi Nurhamzah, Indonesia; Luwiharsih, Indonesia; Idawati Trisno Koamesah, Indonesia; Gunawan Chely, Indonesia; Simplicia Maria Anggrahini Fernandez, Indonesia; Karina Widowati, Indonesia; Made Diah, Indonesia; Erna Mulati, Indonesia; Nurul Ainy Sidik, Indonesia; Giorgio Tamburlini, Italy; Marzia Lazzerini, Italy; Stephen Ntoburi, Kenya; Mike English, Kenya; Elizabeth Molyneux, Malawi; Tom W.J. Schulpen, Netherlands; Oscar Nuñez, Nicaragua; Elena Keshishian, Russian Federation; Titus Nasi; Solomon Islands; James Auto, Solomon Islands; Elmarie Malek, South Africa; Mulaudzi Mphelekedzeni, South Africa; Cindy Stephen, South Africa; Mark Patrick, South Africa; Hugh Reyburn, Tanzania; Festus Kalokola, Tanzania; Lauri Winter, Timor Leste; Domingas Angela Da Silva Sarmento, Timor Leste; Bourdaloue Fernandez Moniz, Timor Leste; Estelvina Alves, Timor Leste; Liborio Da Costa Alves, Timor Leste; John Bridson, United Kingdom; Harry Campbell, United Kingdom; Kerry Davies, United Kingdom; Stephen Kinoti, United States; Peter Campbell, Uzbekistan; Thi Phuong Hoa Dinh, Vietnam; Harish Kumar, WHO India; Hanny Roespandi; WHO Indonesia; Ingrid Bucens; WHO Timor Leste; Severin von Xylander, WHO Vietnam; Andrew Lingililani Mbewe, WHO AFRO, Congo; Aigul Kuttumuratova, WHO EURO, Denmark; Sudhansh Malhotra, WHO SEARO, India; Marianna Trias; WHO WPRO, Philippines; Susanne Carai, WHO Geneva, Switzerland; Thierry Lambrechts, WHO Geneva, Switzerland; Jose Carlos Martines, WHO Geneva, Switzerland; Robert Walter Scherpbier, WHO Geneva, Switzerland; Martin Willi Weber, WHO Geneva, Switzerland.
- Accepted September 17, 2007.
- Address correspondence to Harry Campbell, MD, FRCP, FRSE, Public Health Sciences, Institute of Genomics and Molecular Medicine, College of Medicine and Vet Medicine University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵Duke T, Kelly J, Weber M, English M, Campbell H. Hospital care for children in developing countries: clinical guidelines and the need for evidence. J Trop Pediatr.2006;52 (1):1– 2
- ↵Tamburlini G, Di Mario S, Vilarim JN, Schindler Maggi R. Assessment of quality of care in pediatric wards: experience in Brazil. Proceedings of the 32nd IUALTD Conference; November 1–4, 2001; IUALTD, Paris
- ↵Pivetta S, Bernadino L, Correia M, et al. Assessing and improving quality of pediatric hospital care in Angola. Medicoe Bambino.2002;21 :(9)603– 604.
- World Health Organization. Serious Childhood Problems in Countries With Limited Resources. Geneva, Switzerland: World Health Organization, 2000.
- ↵Tamburlini G, Di Mario SD, Maggi RS, et al. Evaluation of guidelines for emergency triage assessment and treatment in developing countries. Arch Dis Child.1999;81 (6):478– 482
- ↵World Health Organization. Improving the Quality of Hospital Care at First Referral Level. Geneva, Switzerland: World Health Organization/Department of Child and Adolescent Health and Development; 2001
- ↵Choubina P. Respiratory disease program in Malawi is a success. Lancet Infect Dis.2003;3 (11):680
- ↵Campbell H. Integrated care pathways. BMJ.1998;316 (7125):133– 137
- ↵Krug A, Pattinson RC, eds. Saving Children 2004: A Survey of Child Healthcare in South Africa. University of Pretoria and MRCH Unit for Maternal and Infant Health Care Strategies, 2006. Available at: www.mrc.ac.za/maternal/savingchildren.pdf.
- ↵Garrett L. Do no harm: the global health challenge. Foreign Affairs.2007;Jan/Feb:14–38
- ↵Cattaneo A, Buzzetti R, on behalf of the Breastfeeding Research and Training Working Group. Effect on rates of breastfeeding of training for the Baby Friendly Hospital Initiative. BMJ.2001;323 (7325):1358– 1362
- ↵Dobson MB. Oxygen concentrators offer cost savings for developing countries: a study based on Papua New Guinea. Anaesthesia.1991;146 (3):217– 219
- Ahmed T, Ali M, Ullah MM, et al. Mortality in severely malnourished children with diarrhoea and use of a standardized management protocol. Lancet.1991;353 (9168):1917– 1922
- ↵Mancey-Jones M, Brugha RF. Using perinatal audit to promote change: a review. Health Policy Plan.1997;12 (3):183– 192
- ↵Schulpen TW, Lombarts KM. Quality improvement of paediatric care in the Netherlands. Arch Dis Child.2007;92 (7):633– 636
- Copyright © 2008 by the American Academy of Pediatrics