Elsevier

The Lancet

Volume 372, Issue 9642, 13–19 September 2008, Pages 910-916
The Lancet

Articles
How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study

https://doi.org/10.1016/S0140-6736(08)61401-4Get rights and content

Summary

Background

Countries with high rates of child mortality tend to have shortages of qualified health workers. Little rigorous evidence has been done to assess how much the quality of care varies between types of health workers. We compared the performance of different categories of health workers who are trained in Integrated Management of Childhood Illness (IMCI).

Methods

We analysed data obtained from first-level health facility surveys in Bangladesh (2003), Brazil (2000), Uganda (2002), and Tanzania (2000). We compared the clinical performance of health workers with longer duration of preservice training (those with >4 years of post-secondary education in Brazil or >3 years in the other three countries) and shorter duration (all other health workers providing clinical care). We calculated quality of care with indicators of assessment, classification, and management of sick children according to IMCI guidelines. Every child was examined twice, by the IMCI-trained health worker being assessed and by a gold-standard supervisor.

Findings

272 children were included in Bangladesh, 147 in Brazil, 231 in Tanzania, and 612 in Uganda. The proportions of children correctly managed by health workers with longer duration of preservice training in Brazil were 57·8% (n=43) versus 83·7% (n=61) for those with shorter duration of training (p=0·008), and 23·1% (n=47) versus 32·6% (n=134) (p=0·03) in Uganda. In Tanzania, those with longer duration of training did better than did those with shorter duration in integrated assessment of sick children (mean index of integrated assessment 0·94 [SD 0·15] vs 0·88 [0·13]; p=0·004). In Bangladesh, both categories of health worker did much the same in all clinical tasks. We recorded no significant difference in clinical performance in all the other clinical tasks in the four countries.

Interpretation

IMCI training is associated with much the same quality of child care across different health worker categories, irrespective of the duration and level of preservice training. Strategies for scaling up IMCI and other child-survival interventions might rely on health workers with shorter duration of preservice training being deployed in underserved areas.

Funding

Bill & Melinda Gates Foundation and the US Agency for International Development.

Introduction

About 10 million children die every year, with most deaths occurring in low-income countries—mainly sub-Saharan Africa and south Asia.1 However, two-thirds of these deaths could be avoided if all children had access to cost-effective preventive and curative interventions that have been available for several years.2

Maternal, infant, and child survival increase with the ratio of health workers to the population.3 On the basis of empirical data, WHO concluded that countries with fewer than 2·3 health-care professionals per 1000 people are less likely to achieve 80% coverage rates for deliveries by a skilled attendant than are those with a higher ratio of health-care professionals.4 The coverage of measles immunisation has also been associated with health-worker ratio.5 Many high-mortality countries have serious health-worker shortages—eg, the African region accounts for about half of all deaths in children younger than 5 years and has only 3% of the global health workforce.4, 6

An insufficient number of motivated, well-trained health personnel is a major limitation for scaling up effective interventions. Task shifting, or the devolution of selected clinical responsibilities to health workers with shorter duration of preservice training (ie, training undertaken before obtaining a degree from school), is increasingly seen as an option to address the shortages of personnel.7

The Integrated Management of Childhood Illness (IMCI) is a global strategy that has been adopted by more than 100 countries. IMCI has three components: improving performance of health workers, strengthening health systems, and improving family and community practices that are relevant to child health. Its clinical guidelines describe how to assess, classify, and manage children younger than 5 years who have common illnesses. The guidelines are intended for use by all types of health workers (doctors, medical assistants, nurses, or literate paramedical workers) who, after being trained in IMCI, provide care in first-level outpatient health facilities.8 Emphasis is given to the use of clinic visits by sick children, irrespective of the type of illness, as an opportunity for the delivery of preventive interventions.

The Multi-Country Evaluation (MCE) of IMCI assessed the effectiveness and cost of the three components of IMCI in five countries (Bangladesh, Brazil, Peru, Tanzania, and Uganda). Apart from Peru, surveys administered in health facilities gathered data for health-worker performance allowing the assessment of the training component of IMCI. These surveys are done in countries with the highest number of deaths in children younger than 5 years worldwide.1 Doctors and nurses were the only health personnel trained in IMCI in Brazil, whereas paramedical workers were also trained in the other three countries. IMCI training was successfully scaled up in Tanzania and Bangladesh. In Brazil, achieved training coverage was low (<10%), and in Uganda the fast scaling up of training had a negative effect on training.9 Precise estimates of the proportions of first-level facility workers who were trained in IMCI are not available since none of the four countries that we studied routinely collected comprehensive training statistics, indicating inadequacies in their monitoring systems.

In addition to high and equitable intervention coverage, good quality of care is a criterion for improving child health.10 Little rigorous evidence has been done to assess the comparative clinical performance of physicians and nurses, especially in primary health care. A recent systematic review showed that doctor–nurse substitution in primary care resulted in much the same quality of care, although the study had several methodological problems.11 A report from the Brazil IMCI assessment suggested that nurses did as well as doctors, if not better, in several clinical tasks.12 Task shifting of clinical responsibilities is not restricted to doctors and nurses. There is increasing advocacy for a greater involvement of non-physician clinicians, especially in sub-Saharan Africa,13 where such personnel could help to scale up interventions for child survival. However, task shifting takes place within a context and needs to be accompanied by other measures such as standardised training, supervision, certification and assessment, and adaptations of incentives for it to be successful.7 Rigorously designed studies on quality of care that is provided by these health workers are urgently needed for task shifting to be promoted as an evidence-based strategy for improvement of child health.

On the basis of data from four MCE countries (Bangladesh, Brazil, Tanzania, and Uganda), we aimed to assess how different categories of IMCI-trained health workers vary in terms of quality of child care.

Section snippets

Study design and setting

Our analyses are restricted to the first component of IMCI—namely, improvement of health-worker performance. We analysed data obtained as part of the MCE through first-level health facility surveys in Bangladesh (2003), Brazil (2000), Uganda (2002), and Tanzania (2000) to compare the performance of clinical tasks by health workers. We assessed health workers who had received in-service IMCI training. The surveys were undertaken in each country by trained surveyors who assessed the quality of

Results

Table 1 shows the different categories of health workers providing care in every country, the duration of their preservice training, and the number of children that they saw. In Bangladesh, children were seen by medical assistants and subassistant community medical officers, both of whom received 4 years of post-secondary training, and by family welfare visitors, who received 18 months of post-secondary training. Physicians did not manage sick children in the first-level facilities who were

Discussion

Recent interest in the human resources crisis in the health sector in low-income countries4, 5 motivated this reanalysis of data collected between 2000 and 2003 in the multicountry assessment of IMCI. Previous reports from this study showed that quality of care—defined as compliance with the IMCI guidelines for assessment, classification, and management of sick children—was consistently better in areas with IMCI than in comparison areas in the four countries studied.12, 15, 18, 19 This study

References (34)

  • S Sazawal et al.

    Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials

    Lancet Infect Dis

    (2003)
  • The world health report 2006: working together for health

    (2006)
  • Task shifting. Global recommendations and guidelines

    (2008)
  • S Gove

    Integrated management of childhood illness by outpatient health workers: technical basis and overview

    Bull World Health Organ

    (1997)
  • J Bryce et al.

    Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness

    Health Policy Plan

    (2005)
  • P Tugwell et al.

    Applying clinical epidemiological methods to health equity: the equity effectiveness loop

    BMJ

    (2006)
  • M Laurant et al.

    Substitution of doctors by nurses in primary care

    Cochrane Database Syst Rev

    (2005)
  • Cited by (81)

    View all citing articles on Scopus

    Members listed at end of paper

    View full text