| dc.description.abstract | Background: By 2019, the under-five mortality rate in Uganda was 46 deaths per 1000 live births. About 70% of these deaths result from preventable conditions mainly malaria, respiratory infections, diarrheal diseases and neonatal conditions. About 50% of sick children are managed by private facilities but, studies elsewhere show that private health providers tend to be less efficient than those in public facilities. They increase the facility incentives, carry out unnecessary investigations and give unnecessary medications. This thesis examined the quality of healthcare provided for children with pneumonia, malaria, diarrhoea, and young infants with possible serious bacterial infections (PSBI), by the low-level private health facilities (LLPHFs) in Mbarara District, Western Uganda. These conditions were chosen based on the integrated management of childhood illnesses (IMCI) guidelines which should be implemented at low-level health facilities to deliver the minimum health care package. Specifically, the thesis examined the capacity to provide care and the appropriateness of the healthcare. It also explored the referral processes, and, the external support received by LLPHFs to provide healthcare for common childhood infections.
Methods: Four sub studies were conducted concurrently in LLPHFs in Mbarara District, the Mbarara District Health office (DHO) and the Ministry of Health (MoH) in Uganda. To establish the capacity to provide care (sub study I), a cross sectional study was carried out using structured questionnaires and observations to collect data from 110 LLPHFs on availability of treatment guidelines, vital medicines, equipment and diagnostics, and, healthcare workers (HCWs) knowledge of management of common childhood infections. A mixed-methods parallel convergent study was used to assess the appropriateness of healthcare (sub study II). A total of 777 consultations of children with pneumonia, malaria, diarrhoea or PSBI by HCWs were observed and 43 individual interviews carried out with HCWs and policy-makers to get their perspectives on the quality of healthcare. The care was considered appropriate if assessment, diagnosis and treatment were correct, using the IMCI guidelines as the reference standard. A phenomenological qualitative design was used to explore the perspectives on referral process (sub study III) and external support given to LLPHFs providing health care for children (sub study IV). Individual interviews were carried out with 46 key informants in sub study III and 43 key informants in sub study IV.
Results: Capacity: Majority of the LLPHF had in stock the basic diagnostics such as malaria rapid diagnostic tests and vital medicines for treating the common childhood infections, such as amoxicillin and artemether/lumefantrine. Only 4% of the LLPHFs had the IMCI guidelines. About 57% of the HCWs scored averagely for knowledge on management of common childhood illnesses. Appropriateness of care: The proportion of consultations with appropriate care was 11% for pneumonia, 14% for malaria, 8% for diarrhoea and ˂1% for PSBI. The care was less likely to be appropriate for children with diarrhea (OR 0.29, 95% CI: 0.11–0.76, p = 0.012), as well as those able to feed orally (OR 0.07, 95% CI: 0.03–0.13, p < 0.001). The care was likely to be appropriate among more severely ill children with danger signs including those who were vomiting everything (OR 10.1, 95% CI: 4.41–22.1, p < 0.001), had seizures (OR 7.54, 95% CI: 2.97–19.1, p < 0.001), or were lethargic or had impaired consciousness (OR 4.42, 95% CI: 1.03–19.1, p = 0.046).
Referral: The processes of referral were shaped by the patients’ clinical characteristics, caretaker ability to pay and health worker perceptions. Caretaker non-adherence to referral and inadequate communication between lower-level and higher referral facilities were the major challenges faced.
Support: There is hardly any external support provided to LLPHFs to manage childhood illnesses is inappropriate in terms of support supervision and dissemination of policies and guidelines. Health providers emphasized a need for technical capacity building, provision of guidelines as well as adopting a more supportive supervisory approach.
Conclusions and recommendations: While over 70% of the LLPHFs in Mbarara District had vital first-line medicines for treatment of common childhood illnesses, majority lack clinical guidelines. In addition, the LLPHF do not receive adequate support and guidance to enable them deliver quality healthcare. Consequently, most children with common infections attending these facilities were inappropriately managed. Caretaker non-adherence to referral and inadequate communication between lower-level and higher referral facilities are the major challenges faced in the referral process. In order to improve the quality of healthcare provided by LLPHFs, capacity building with emphasis on innovative knowledge and skills raising interventions, provision of clinical guidelines and supportive supervision are key strategies. Research should be carried out on the feasibility and the impact of innovative modes of knowledge and skills transfer to LLPHF such as use of virtual tools. | en_US |
