Quality of care
Everyone should be able to access good quality healthcare in a way and place that is right for them. Yet in many districts across Nepal, health services simply do not meet the needs of the local population.
A maternal mortality and mobility study conducted in Nepal in 1998 found that poor quality services and a lack of readiness at health facilities were major reasons for the high maternal death rate reported. Maternal, newborn and child health face multiple challenges if service quality is to improve, from overcoming shortages of skilled human resources and commodities, to helping staff practice and maintain acquired skills at service delivery points. Studies have also shown that overcrowding at referral hospitals and the underutilisation of rural health facilities add to these challenges and adversely affect health outcomes while discouraging potential users from seeking services.
If we are to increase maternal and neonatal survival rates, we urgently need to improve the quality of services available for mothers and their babies.
Weak management and the traditional focus on service expansion over service quality are some of the leading causes of poor quality health care in many developing countries. A continuous quality improvement and assurance process covering areas such as human resources, infrastructure, equipment and supplies is needed. This requires both dedicated budgets and proactive leadership. An integrated approach to service delivery is also important including developing public-private partnerships to assure service quality, improving referral systems, increasing the availability of other services and improving patient care. Health facilities should be strategically located to enable more users to access them, and monitoring and evaluation should be strengthened to capture quality of care performance. Accountability should also be strengthened by bringing together communities to raise awareness on the right to quality health care and to improve local health services. This requires both strong political will and high receptivity to user voices at all levels.
We promote quality of care across seven areas:
- Strengthening human resources so that health workers are proficient, regulated, respectful and motivated, and deliver services using recommended standards and guidelines
- Improving infrastructure in line with basic quality of care requirements
- Ensuring equipment and medicines are properly stored, maintained and used by trained and skilled staff
- Improving clinical practices to ensure that care is provided in line with internationally recognised guidelines and consistent with national policies
- Establishing institutional structures that promote gender equality and social inclusion at all levels of the health system to encourage respect and equal access for all service users
- Strengthening continuity of care by building networks of care and integration from the community up and the secondary/tertiary facility down
- Developing rapid tools to collect actionable data that can inform the design of strategies to scale up quality services and build on what works.
We piloted a hospital quality improvement process (HQIP) in two districts to improve the quality of care from admission to discharge, particularly for child birth. This involved improving basic skills, providing financial incentives for staff and institutions, and supplying essential equipment. These, in turn, led to higher levels of awareness, concern and engagement with quality of care so that it became a priority with health workers. In Taplejung, eastern Nepal, we piloted various ways of improving access to quality health services in remote areas. Needs assessments identified improving obstetric care and access to medical abortions as local priorities. Accordingly on-site support and mentoring was provided, including advice on improving decision making for timely referrals. We also supported the development of clinical mentors in district hospitals to sustain quality improvements in their own facilities and at rural health facilities.
We revised all standard designs for health infrastructure to improve patient and staff flows, protect clean areas, reduce cross-contamination and safely dispose of medical wastes. A technical specifications bank was also developed to assist in the procurement of quality medical instruments and equipment.
Key results and achievements
- The HQIP was piloted in two hospitals with learning used to develop indicators to monitor and evaluate service quality and to link the hospitals to the centre. This initiative also informed the ministry’s broader Quality Assurance system.
- The Family Health Division provided funds for the scale-up of HQIP with support from our advisers to revise tools and establish quality improvement processes at district hospital level.