2011年-世界发展银行全球_Tajikistan_-_Quality_of_Child_Health_Services_38页_509kb

Summary of the Quality of Child Health Services in Tajikistan

Core Content

This report, prepared by the World Bank with support from GAVI, evaluates the quality of child health services in Tajikistan, focusing on primary health care (PHC) facilities and the effectiveness of the Family Medicine (FM) and Integrated Management of Childhood Illness (IMCI) training programs. The study was conducted in 19 districts across Khatlon region, Sogd region, Rayons of Republican Subordination (RRP), and Dushanbe City, and involved 300 sick children.

Main Findings

1. Child Health Outcomes and MDG Targets

• Child Mortality Rates: Tajikistan's infant mortality rate (IMR) is currently 52 per 1,000 live births, and the under-five mortality rate (U5MR) is 61 per 1,000 live births.
• MDG Goals: The country aims for a two-thirds reduction in child mortality by 2015, which would require an IMR of 29.6 and a U5MR of 39.3.
• Preventable Illnesses: Pneumonia, diarrhea, malaria, measles, and under-nutrition are the leading causes of child mortality, contributing significantly to morbidity and mortality.

2. Regional Variations in Child Health Indicators

• Lowest Rates: The Gorno-Badakhshan Autonomous Oblast (GBAO) and Dushanbe City have the lowest IMR and U5MR.
• Highest Rates: Khatlon region has the highest rates, with IMR at 102 per 1,000 and U5MR at 81 per 1,000.
• Key Risk Factors: Short breastfeeding duration, late vaccinations, low use of oral rehydration therapy (ORT), micronutrient deficiencies, and low antenatal care visits are associated with poor child health outcomes.

3. Quality of Clinical Care

• Danger Signs Assessment: Only 45.7% of children were assessed for all three key danger signs (inability to drink, vomiting, convulsions), far below the ideal 100%.

• Regional Performance: The RRP had the worst performance (4.3%), while other regions ranged from 46% to 64%.

• Training Impact: Providers trained in the nine-day IMCI course performed better than those in shorter courses.

• Weight Assessment: Only 26.7% of children had their weight checked against growth charts, which is essential for identifying malnutrition.

• Regional Comparison: The RRP had the lowest proportion of weight assessments (Figure 5).

• Provider Type: Children seen by family doctors were more likely to have their weight assessed than those seen by pediatricians (30.2% vs. 14.9%).

• Feeding Practices Assessment: 45.3% of children under two years were assessed for feeding practices, including breastfeeding, complementary feeding, and feeding changes during illness.

• Nutritional Status: Stunting is prevalent, with 29% of children under five nationwide and 36.9% in Khatlon region.

4. Treatment and Medication

• Antibiotic Use: Only 42% of children needing antibiotics received them, and 8% received a first dose during the visit.
• Diarrhea Management: 84% of children needing oral rehydration salts (ORS) received them, but only 22% with anemia received iron supplements.
• Vaccination Coverage: Measles vaccination rates were 41% in RRP and 77% in Sogd (Figure 3).

5. Health System Issues

• Training and Supervision: The current FM retraining program (six months) does not seem to improve adherence to IMCI guidelines.
• Supervision Gaps: Supervision of PHC workers is irregular, and training is not systematic.
• Resource Constraints: Essential drugs, vaccines, and equipment are often unavailable in PHC facilities.

Key Recommendations

Immediate Actions

1. Ensure Availability of Essential Resources: Stock PHC facilities with essential antibiotics, vaccines, and drugs, especially in RRP.
2. Improve Supervision and Support: Implement routine supervision and support systems for PHC providers to reinforce adherence to clinical guidelines.
3. Enhance On-the-Job Training: Provide intensive training on child growth monitoring and nutrition for PHC workers.
4. Close Gaps in Referral and Diagnosis: Improve the referral process and ensure accurate diagnosis of sick children.

Medium-Term Actions

1. Evaluate FM Training Programs: Conduct an independent assessment of FM retraining programs to ensure relevant and effective content.
2. Improve Trainer Competency: Offer continuous skills improvement training for FM trainers at four main postgraduate training centers.
3. Revise Payment Systems: Explore incentive-based payment systems to improve the quality of PHC services.
4. Strengthen Quality Assurance: Enhance the current system of quality assurance in PHC facilities.

Conclusion

The quality of child health services in Tajikistan remains suboptimal, with significant gaps in clinical assessment, diagnosis, and treatment. While the government has introduced FM and IMCI strategies to improve care, these have not yet led to the desired outcomes. The study highlights the need for better training, supervision, and resource allocation to ensure that PHC facilities can deliver effective care to children. With careful planning and coordination, the Ministry of Health (MOH) can implement these recommendations and improve child health outcomes.