Consistent with research in other developing countries [1–6], we found that the quality of hospital care to under-fives in Bangladesh is poor and requires improvement. Deficiencies were found in a number of interconnected areas including in relation to triage systems, clinical case management and monitoring, the quality of neonatal care, essential hospital support systems and drugs, and hospital and child health infrastructure. Addressing these quality issues may not only improve the standard of care provided, but also improve access. For instance, Bari et al. found that perceptions of high quality care, alongside the availability of treatment, and the fact that care was free, were reasons cited by parents of newborns for accessing hospital care in one sub-district in Bangladesh .
Many deaths occur in the first 24 hours after arrival at a hospital and thus urgent intervention can be critical to child survival . The WHO has developed guidelines for triage and emergency treatment of common emergency conditions that occur in under-five children in developing countries . When accompanied by a short training course, the use of these guidelines by nurses was found to be effective in facilitating the identification and management of severely ill children in a hospital in Brazil .
This assessment found that out-patient case management and care practices were poor despite all but one hospital in our sample having IMCI-trained providers.
A study in Bangladesh highlighted the potential for incomplete assessments, and incorrect treatment amongst IMCI trained providers . The reinforcement of training and provision of supportive supervision were factors that different studies identified as contributing to health workers performance in relation to IMCI [19, 20].
Our findings illustrate that essential drugs, equipment and supports also need to be made available so that health providers can provide care based upon evidence-based guidelines. Even the best trained providers cannot treat severely ill children when, for instance, the essential drugs needed to do so are not at their disposal. Such essential supports were generally found to be lacking in the hospitals we assessed, which may be due to supply chain and stock management issues. While supply chain issues may take time to rectify, supervision may be a feasible way of improving stock management . Similarly, inadequate laboratory support, as was found in many hospitals in this assessment, is likely to impact upon the quality of the diagnosis and treatment of severely ill children. Likewise a lack of equipment, as in the case of weighing machines for example, compromises proper assessment and leads to inappropriate treatment dosages given. English et al. document a similar situation in rural Kenya, in which they found between 30% to 56% of necessary items for paediatric care to severely ill children and newborns to be lacking in hospitals .
Although hospitals are supposed to function as places of healing and recovery, our findings point to the possibility that, if neglected, the hospital environment itself can have the opposite effect. Poor physical infrastructure such as unsafe drinking water or the lack of a back-up power supply found in many hospitals in our sample for instance, threaten to compromise patient safety.
The results of our assessment, when interpreted alongside the quality of care literature, [1
] highlight the interconnectedness of the many dimensions that influence the quality of hospital care for children. In order to have the greatest impact on improving hospital quality, our findings suggests that it is not enough to focus solely on improving one dimension of hospital care alone whilst others remain neglected. For example increasing the training of hospital staff or providing them with refresher training is likely to increase clinical case management skills but is only likely to result in quality gains if the essential assessment and monitoring equipment, drugs, and laboratory support are present. And even if the necessary equipment and drugs are available to providers in order to optimize their clinical case management skills, positive outcomes for patients may be undermined by the hospital environment itself. Similarly even if improvements are made in other areas, deficient triage systems may mean that children most in need of urgent care do not receive the care they need. Therefore our assessment points to the need for an integrated package of quality improvement measures to be implemented. This would ideally include measures such as:
Ongoing training, supportive supervision and guideline development to increase clinical case management skills of providers
Investment in essential drugs, equipment, and laboratory supports to optimise the clinical case management skills of providers
Investment in human resources, and in improving hospital infrastructure to ensure that the hospital environment is safe, and
The development of triage and other systems based upon guidelines to prioritise those most in need.
Regular feedback on hospital performance to motivate managers and workers, and sustain quality improvement
In Bangladesh particular emphasis and investment within an integrated quality improvement package needs to be placed on neonatal care. While some of the quality improvement measures that we have suggested may require significant investment and time to implement, others such as providing ongoing training, supportive supervision, guideline development and the development of triage systems in hospitals can be positive first steps. For instance, Ayieko et al. found that a multifaceted intervention, which included evidence-based clinical practice guidelines, training on emergency triage assessment and treatment, the provision of job-aides, local facilitation, and regular supervision and face to face feedback resulted in improvement in paediatric care in Kenyan district hospitals . The authors also found that the implementation of the full intervention resulted in greater improvement in paediatric care practice as compared to a partial intervention, which included less quality improvement strategies. This reiterates the notion that multifaceted interventions may be more effective in improving the quality of care in resource poor settings than single interventions .
The persistence of quality of care issues in resource poor settings suggests that similar underlying issues may be present. Many of the issues that we and others have reported including poor hospital infrastructure, essential supports and drug availability may reflect health system deficiencies. But, as Travis et al. point out, health system strengthening has not been given adequate attention in comparison to specific disease focussed interventions . Similarly, Rowe et al. argue that: ″There is a growing imperative to scale up delivery of key health interventions to meet the Millennium Development Goals. However, simply scaling up interventions in weak health systems that deliver poor quality services is likely to waste precious resources and fail to show the anticipated improvements in health″. (pg 8) . Because health system strengthening has been relatively neglected as part of the global health agenda, the potential for initiatives such as an integrated quality improvement approach to enhance system wide capacity is great.
National benchmarking or hospital accreditation may be possible ways in which an integrated quality improvement approach can occur in Bangladesh. Zambia has embarked upon a national hospital accreditation programme, in which hospitals undergo educational and accreditation surveys and are provided with feedback on how they can meet agreed-upon standards for accreditation . This represents the next step in the hospital quality improvement process in Bangladesh.
An important foreseeable barrier to this pursuit is resource scarcity in developing countries like Bangladesh. However, one place to start might be a reassessment of the current allocation of resources. Carai et al. note that tertiary hospitals have tended to receive the large share of hospital funding even though the majority of severely ill children are treated in referral level facilities . Whilst emphasis on primary care and prevention is needed, increasing investment in referral level facilities is also needed if child survival activities, such as IMCI, are to be successful.