Social determinants of health play a major role in influencing exposure and susceptibility to disease, and together with inequalities in access to care are the main causes of the striking differences in child morbidity and mortality across countries and regions. Since the Convention on the rights of the Child (CRC) came into force nearly a quarter century ago, child rights-based approaches to health have had an increasing impact on state and organizational policies for child health services.1 Looking toward the future, with advances in our knowledge of social epidemiology and the impact of social and environmental determinants on health and well-being throughout the life course, a child rights and equity-based approach to health will become increasingly relevant. Quality of care (QoC), at primary care and hospital level, play an important role in influencing child health outcomes, particularly in low resource settings. However, despite evidence that there is substantial scope for quality improvement even without major investments, and that inequities in quality may be as important as inequities in access, the quality of care issue has been neglected in international as well as in national programs aimed at decreasing child mortality.2
Of the almost 7 million children who die every year before the age of five globally, 99% occur in developing countries.1 Most of these deaths are due to a few treatable and preventable diseases, for which effective interventions are already available.3 A particular focus will be newborn deaths, as neonatal mortality now accounts for more than 40% of child deaths globally; most newborn deaths are preventable.1Achieving broad coverage of health interventions and optimizing health outcomes is a majorchallenge for low- and middle-income countries (LMICs). In particular, data to support routine monitoring of hospitalcare, outcomes and uptake of innovations arecompletely inadequate but much needed in LMICs.4 Based on current guidelines it has been estimated that about 10-20% of sick children presenting for primary care, i.e. the most severely ill, may require referral to a first referral or district hospital.2 The quality of care provided in these hospitals is likely therefore to have a major impact. 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.5 Hospital assessment exercises supported by WHO over the past few years have found similar deficiencies in countries including Cambodia, Indonesia, Kazakhstan, Russia, Solomon Islands and Timor Leste.6 Similar observations were made in studies in Kenya, with clear indications that most practitioners were neither aware of nor followed international guidance on best practice.7 What we do know is that improving quality of care at scale nationally for low income countries such as Kenya, is not only cost effective but from a child rights point of view, essential.8
Our goal in TAG-QC is thereforeto ensure that paediatricians supported by their Paediatric Societies and in collaboration with global agencies dealing with reproductive, maternal, newborn and child health, provide quality care to all children /young people who are in need of healthcare without discrimination, in an environment that is safe and appropriate for the age and stage of development of the child /young person, in order to help them achieve optimum health and wellbeing.
The following foundational principles underpin the strategic directions for Quality of Care:
Child: holder of the right to enjoyment of the highest attainable standard of health and wellbeing, owner of evolving capacities during growth and development across the life course until age 18.
Rights: Universal, indivisible, interdependent and interrelated values; acting for a child's right to health implies commitment toward the realization of other rights.
Health: process toward physical, mental, social and spiritual well-being influenced by a wide spectrum of determinants (genetic, biological, social, economic, cultural, environmental); and as a resource for the full realization of the human potential.
The QoC issue was first addressed by a plenary lecture and symposium given by Giorgio Tamburlini at the IPC held in Cancun in 2004. The issue was again addressed in Athens with a symposium which reported several experiences of quality assessment carried out at country level. The issue of evidence based paediatric practice was addressed by a plenary lecture at the Athens meeting. IPA has been thereafter active in several meetings on this subject including a meeting organised by WHO in Bali in 2008 and several regional meetings. IPA established a working group on QoC and evidence-based Pediatrics (EBP). The first technical advisor was Giorgio Tamburlini, former SC member, who is also assisting WHO in several programmes aimed at improving quality of care and disseminating existing guidelines at country level. Training modules have been developed, with the proposal that joint IPA-WHO training workshops on EBP and QoC could be run at national or regional levels. A modular, flexible approach was proposed so that training modules can be adapted to the contexts, resources and needs of national/regional settings.
In 2014, QoC moved from a Program to a Technical Advisory Group, chaired by Shanti Raman, hereinafter called TAG-QC. The TAG will now build on the critical early foundations established by Dr Tamburlini and bring in some important quality elements from the children's rights in health services and also harness the impetus that is flowing from the Every Newborn Action Plan.
Why is it important for IPA to be involved in Paediatric Quality of Care?The role of National Paediatric Societies
There is now substantial global experience of strategies and interventions that improve the quality of care for children, particularly in hospitals of countries with limited resources.9 WHO has developed a toolkit containing adaptable instruments, including tools for quality assessment, a framework for quality improvement, evidence-based clinical guidelines in the form of the Pocketbook of Hospital Care for Children, teaching material, and mortality audit tools.10 These tools have been field-tested by doctors, nurses and other child health workers in many developing countries. Another parallel process has been the evaluation of children's rights in hospital services, developed by the WHO Health Promoting Hospitals- Children& Adolescents task force.11 The self-evaluation tool has been used by hospitals and health services across Europe and Australasia, to assess how well health services actually uphold and promote children's rights. The challenges for all these programs and initiatives are to bring these and other strategies to scale, and to support research into their use, impact and sustainability in different environments. Another important area in global paediatric practice has been the growth of evidence-based and applied research, again with paediatricians leading this charge and QoC being at the core.12 Quality of careis now being seen as a core component of the Every Newborn Action Plan (ENAP), which states that every woman and her newborn will receive high-quality and respectful care.13 The recent BMC Pregnancy and Childbirthsupplement has up-to-date analyses on what it will take to scale up quality initiatives, what the health system bottlenecks with their solutions are, and the value of mortality audits in improving maternal and newborn quality of care.14-17
IPA has a unique role in reaching down to frontline clinician level, through national societies, as well as an enviable role in global health and development through strategic partnerships. Hospital care represents in most countries the very heart of paediatricians' role and therefore IPA must see in this area a priority area for collaborations with national societies. Achieving universal health coverage—a key plank of the Sustainable Development Goals, that supports high-quality care will require that health systems are designed to integrate the delivery of health services with the generation of new knowledge about the effectiveness of these services.18 Paediatricians supported by their professional societies, must be at the forefront of developing Learning Health Systems particularly in LMICs, for their immediate and longer term benefits and to avoid having to retrofit health systems with the capability to promote learning.National and regional Paediatric Societies should play an important role in improving QoC across the health system by promoting and disseminating existing clinical standards (such as I(N)MCI guidelines and the Pocket book for hospital care), as well as promoting training and CME on quality of care assessment, tools and quality improvement strategies. Additionally, IPA can and should uphold and promote children's rights, their participation in planning the highest quality of services to suit their unique needs,19 via partnerships with relevant global organisations such as United Nations Fund for Children (UNICEF), Department of Maternal, Newborn, Child and Adolescent Health-WHO and International Society for Prevention of Child Abuse & Neglect (ISPCAN).
Between 2014 and 2016, the focus of TAG-QC will be on:
1. Mapping activities undertaken by national and regional paediatric societies in the quality and safety and child rights arena. Technical Advisor and Committee hasdevelopedan e-tool/checklist for dissemination to IPA member societies.
2. Promoting and monitoring QoC activities globally, with a particular focus on children's rights in health services, quality and safety initiatives in national and regional Paediatric societies, district level paediatric hospital care and Every Mother Every Newborn quality activities.Committee members will share and disseminate information via email and skype teleconferences
3. Planning for TAG-QC sessions at the 2016 International Pediatric Congress.
4. Form partnerships with other relevant global agencies such as UNICEF, WHO andISPCAN to push for training and research into the highest quality of care for children and young people, whilst promoting and upholding their rights.
The major event planned is the 2016 International Pediatric Congress in Vancouver. During 2015, TAG-QC will host a pre-Congress workshop on the day prior to the official start of the Congress and host a seminar within the Congress program on Quality and Safety in Paediatric care.
1. UNICEF, WHO, The World Bank. Levels and trends in child mortality: report 2013. New York: United Nations Children's Fund, 2013.
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13. WHO. Newborn health: draft action plan. Geneva: World Health Organization, 2014.
14. Dickson K, Kinney M, Moxon S, et al. Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Pregnancy and Childbirth 2015; 15(Suppl 2): S1.
15. Sharma G, Mathai M, Dickson K, et al. Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy and Childbirth 2015; 15(Suppl 2): S2.
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18. English M, Irimu G, Agweyu A, et al. Building Learning Health Systems to Accelerate Research and Improve Outcomes of Clinical Care in Low- and Middle-Income Countries. PLoS Med 2016; 13(4): e1001991.
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