Low quality of care: a constraint to the implementation of community health insurance

Transcription

1 Low quality of care: a constraint to the implementation of community health insurance Somé Florent 1, Pfeiffer Karolin 2, Sauerborn Rainer 2 1 Centre de Recherche en Santé de Nouna, Burkina Faso 2 University of Heidelberg, Allemagne The story line about quality (1985-today) Quality = infrastructure + process + outcome Inputs: Poor countries need inputs: 1) buildings and equipment, 2) training Done, but no effect on quality Process: standards of care written and taught reviewed during supervision Done, but no effect on quality TQM implemented Done, but no effect on quality What now?

2 Work load per health worker Formation sanitaire Consultants Consultations Consultants + consultations Charge en malades/jour par formation sanitaire Charge en nombre de malades par agent par jour Sans bénévole Avec bénévole CM Tansilla Balavé Sanaba Kouka Les 4 CSPS CM + CSPS Table 1. Charge de travail des différentes formations sanitaires The higher the input, the lower the quality. Users: scores per health care center Baltussen et al. 2002

3 Observed quality of care!"#$ % #!"!! "!"# $% #!"# "% &'()*&+,--./ & #!" " '!" # && '!" 0- %!#( ' 0- &1# "!$$ '!$$ ( "'!$$ $%.-!$$ '#.- $'!$$ ('!$$ "' )!$ $'!$ "$ *+)&!# " $!# $ &1## ' )) "#! $(.-! "#.- )) $#!( # "!( ' &#' + "!" ' %%!" ) #!(' '.- #!($ ' 0- $!' ' $!'" $,-# The example: malaria care Background In 2002 malaria was responsible for : 40% of the total reasons of visits to health facilities (HF) 45% of the total children s admission to HF 45% of the total under fives deaths occurring in HS Malaria is cause and consequence of poverty Study results on: inputs process

4 PROCESS: Staff attitudes and practices Qualité de la prise en charge du paludisme selon les données des dossiers cliniques En 2001, 178 cas de paludisme grave, dont 8 référés ont été hospitalisés en pédiatrie a l hopital du district 88,2% des patients avaient < 5ans La goutte épaisse a été demandé pour 50,3% des enfants hospitalisés 9 enfants sont décédé Prise en charge adéquate chez 50,6% des enfants

5 Disponibilité des médicaments, consommables médicaux, matériel médico technique Les antipaludiques, les antipyrétiques, les solutés isotoniques 500 ml, et les principaux consommables médicaux étaient disponibles Pas de rupture de stocks en réactifs et consommables utilisés dans le diagnostic du paludisme. Le matériel de base (thermomètre, stéthoscope, tensiomètre, pèse personne ) était disponible Pilot study on malaria care Steps (IMCI standards) Patient reception History taken Physical examination Observance of standards (n=49) (%) ,0 0 Prescription/counselling 1 2,0

6 Relationship between the age of the patient and the quality of the prescription Age group Correct prescription (%) Wrong prescription (%) Total (%) 0 5ans 5 (26,3) 14 (73.7) 19 (100) > 5ans 16 (55,2) 13 (44.8) 29 (100) Total 21 (43,8) 27 (56.2) 48 (100) P=0.048 Study 2: Observation, re-examiniation, lab confirmation, follow-up All patients presenting at CSPS: ask for consent All patients: observation and reexamination and quantitative parasitemia Only patients with confirmed malaria (1) : Blood sample for CQ assessment/pcr Only patients with confirmed malaria: Blood sample for CQ/PCRassessment on day 14 CQ = Chloroquine, PCR=polymerase chain reaction (1) Definition of confirmed malaria cases: axillary temperature >= 37.5 C and >= 5000 parasites/µl

7 Results (1) Participation rate 96% 1101 consultations observed 1101 reexaminations and quantitative parasitemia 235 cases of confirmed malaria Results (2) Clinical diagnosis malaria in 714 cases (out of 1101) = 64.9% Other major diagnoses: Parasitic infections 142 (12.9%) Bronchitis 133 (12.0%) Cough 48 (4.4%)

8 Clinical diagnosis versus lab-confirmed malaria Clinical diagnosis Lab-confirmed malaria Yes No TOTAL Yes No TOTAL Sensitivity = 82.2% Specificity = 30.1% PPV = 35.9% NPV = 85.9% Overdiagnosis: 3.8 fold Chloroquine blood level before and after treatment therapeutic blood level: ng/ml below therapeutic area in therapeutic area above therapeutic area day 0 day 14

9 Problem Quality improvement: trials and errors Research Intervention Infrastruct, equipm t Supervision Standards care Drugs Financial access Quality manag t Provider motivation District autonomy , blocked ongoing ongoing ++ +/- good MEG + CBI ongoing revisited performance based MoH on board Merci

10 Publications on quality of care Sauerborn R, Nougtara A, Bidiga J, Sorgho G, Tiebelesse L, Diesfeld H-J. (1989) Assessment of MCH-services in the district of Solenzo, Burkina Faso - II) Acceptability. Journal of Tropical Pediatrics 35 (Suppl. 1): Sauerborn R, Nougtara A, Bidiga J, Sorgho G, Diesfeld H-J. (1989) Assessment of MCH- services in the district of Solenzo, Burkina Faso - III) Effectivity of MCH-services in detecting of and caring for mothers and children at risk. Journal of Tropical Pediatrics 35 (Suppl. 1): Reerink I, Sauerborn R. (1996) Quality of primary health care in developing countries recent experiences and future direction. International Journal of Quality of Health Care 8(2) Krause,G., Schleiermacher,D., Borchert,M., Benzler,J., Heinmüller,R., Ouattara,K., Coulibaly,S., Diasso,I., Ilboudo,A., & Diesfeld,H.J. (1998). Diagnostic quality in rural health centers in Burkina Faso. Trop Med Int Health, 3, Krause G., Benzler J., Heinmüller R., Borchert M., Koob E., Ouattara K. Diesfeld HJ (1998). Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso. Health Policy Plan, 13, Krause, G., Borchert, M., Benzler,J., Heinmüller, R., Kaba, I., Savadogo, M., Siho, N., & Diesfeld, H.J. (1999). Rationality of drug prescriptions in rural health centers in Burkina Faso. Health Policy Plan, 14, Krause G, Sauerborn R. (2000) Community-effectiveness of care - the example of malaria treatment in rural Burkina Faso, Annals of Tropical Pediatrics, 7: Sauerborn R. (2002). Low quality of care in low income countries is the private sector the answer? Intl. J Qual Care. 13(4): Baltussen RMP, Yé Y, Haddad S, Sauerborn R. (2002) Perceived quality of care of primary health care services in Burkina Faso. Health Policy and Planning. 17(1) Baltussen R and Yé Y. (2005) Quality of Primary Health Care services as perceived by Users and Non-Users in Burkina Faso. International Journal for Quality in Health Care (Accepted). Somé F, Sax S, Marx M, Baltussen R, Sauerborn R. (2005) The implementation of quality assurance in district health services in Nouna, Burkina Faso. Submitted. Pfeiffer K, Some F, Sauerborn R. (2005) Low quality of malaria care for children under 5 years in rural health facilities in Burkina Faso. Submitted.