Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis

Abstract

BackgroundArua district, in Uganda, hosts some of the largest refugee camps in the country. The estimated prevalence of moderate and severe acute malnutrition in children is higher than the national estimates (10.4 and 5.6% respectively, compared to 3.6 and 1.3%). This study aimed at assessing the quality of care provided to children with acute malnutrition at out-patient level in such a setting.MethodsSix facilities with the highest number of children with malnutrition were selected. The main tool used was the National Nutrition Service Delivery Assessment Tool, assessing 10 key areas of service delivery and assigned a score as either poor, fair, good or excellent. Health outcomes, quality of case management and data quality were assessed from the health management information system and from the official nutrition registers.ResultsAll facilities except two scored either poor or fair under all the 10 assessment areas. Overall, 33/60 (55%) areas scored as poor, 25/60 (41%) as fair, 2/60 (3.3%) as good, and none as excellent. Main gaps identified included: lack of trained staff; disorganised patient flow; poor case management; stock out of essential supplies including ready-to-use therapeutic foods; weak community linkage. A sample coverage of 45.4% (1020/2248) of total children admitted in the district during the 2016 financial year were included. The overall mean cure rate was 52.9% while the default rate was 38.3%. There was great heterogeneity across health facilities in health outcomes, quality of case management, and data quality.ConclusionThis study suggests that quality of care provided to children with malnutrition at health center level is substandard with unacceptable low cure rates. It is essential to identify effective approaches to enhance adherence to national guidelines, provision of essential nutritional commodities, regular monitoring of services and better linkage with the community through village health teams.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3366-5) contains supplementary material, which is available to authorized users.

Nutritional services for children in Beira, Mozambique: a study reporting on participatory use of data to generate quality improvement recommendations

“…High rates of abandons similar to what observed in this study were reported by other evaluations in sub-Saharan Africa 18. Abandons may be due to multiple underlying causes, including: low perception of the need/advantages for accessing care, difficulty in accessing care due to lack/cost of transports, conflicting priorities for the mother such as the need for working and attending other children, poor information about service provision, perception of poor QoC and lack of effective systems for tracing defaulters.…”

“…The significant heterogeneity in health outcomes detected among HCs, in particular for children with MAM, is in line with previous observations, reporting large heterogeneity in QoC, even among nearby facilities 17 18 35. Literature and experience in the field have showed that the identification of ‘best performers’, and their appointment as local drivers of a quality improvement process (ie, by actively engaging champions in diffusing best practices in the nearby facilities), can actually help implementing changes 34.…”

“…Similarly, an assessment in Benin15 observed that only 47.4% of the HCs were using the growth charts, 35% could not perform basic anthropometric measurements and no doctors provided nutritional counselling. A recent study in Uganda reported a mean cure rate among malnourished children treated at HCs of 52.9% 18. Lack of adherence to WHO recommendations was also reported in Brazil 17.…”

“…Previous studies highlighted major gaps in the QoC provided to children with malnutrition in low-income and middle-income countries (LMIC), although so far only few assessments were published 14–18. A participatory use of data to generate recommendations to improve the QoC for mother and children has been widely promoted by the WHO 19.…”

Mapping evidence on malnutrition screening tools for children under 5 years in sub-Saharan Africa: a scoping review protocol

“…Moreover, due to a lack of simple validated methods, malnutrition screening is not widely and correctly performed [17,18]. Research studies conducted in South Africa and Uganda have shown that health professionals have inadequate knowledge of available nutritional status interpretation tools as gaps have been identified [19,20]. Moreover, the level of evidence on nutritional screening tools to predict early malnutrition at community levels in high disease burdened settings such as SSA is unclear.…”