Implementation status of self-assessment/peer-group discussion program: a bottom-up approach of monitoring/supervision in improving quality of health services.

BACKGROUND: Monitoring/supervision is an essential component for improving the quality of health services including rational use of medicines. A new bottom-up approach of monitoring/supervision consisting of self-assessment/ peer-group discussion was found to be effective in improving prescribing practices. The new strategy significantly improved the prescribing practices based on standard treatment guidelines. The government has implemented it as a Program in primary health care services of Nepal. This article aims to share the implementation status of the self-assessment/peer-group discussion Program for improving the prescribing practices of common health problems and availability of drugs in the district health system. METHODS: Concurrent mixed research design was applied for data collection. The data were collected at different levels of health care system using in-depth interviews, participatory observations and documentary analysis. RESULTS: The Management Division, Department of Health Services implemented the Program in 2009-10 and the PHC Revitalization Division, DoHs is the implementation division since 2010-11. The Program comprised revision of participant's and trainer's manuals, training of trainers and prescribers, finalisation of health conditions and indicators, distribution of carbon copy prescription pads, and conduction of peer-group discussions.The Program was implemented in number of districts. CONCLUSIONS: The government made the policy decision to implement the Program for monitoring prescribing practices and the availability of free drugs in districts. However, it has covered only few districts and needs escalation to cover all 75 districts of the country.

Community intervention to improve knowledge and practices on commonly used drugs.

BACKGROUND: World Health Organisation (WHO) estimates that about half of all medicines are inappropriately prescribed, dispensed and sold and about half of all patients fail to take their medicines properly. OBJECTIVE: The overall objective of the study was improving use of medicines in the community by creating awareness among different target groups. MATERIALS AND METHODS: It was a pre-post comparison of intervention implemented at the community level in purposively selected Bhaktapur District of Kathmandu Valley, Nepal. The study was conducted in the private schools of the study district. Twelve schools were randomly selected. Thereafter, students from 6-9 grades were listed from the selected schools. Then 15% of the total students in each grade were randomly selected to get six students from each grade of the each school, totaling 288 students. The households of the selected students served as the sample households for the study. Thus, there were 288 households sampled for the study. The intervention and the targeted intermediary groups consisted of a. training of schools teachers b. training of journalists c. interactive discussions of trained school teachers with school children using key messages and c. communication of key messages through the local F.M. radio, newspaper/magazine. RESULTS: There was a significant increase in correct knowledge on action of antibiotics and excellent knowledge on the methods of administration of antibiotics of households after the intervention. Similarly, there was a significant increase in knowledge on cough as a disease and a significant decrease in the use of cough medicines after intervention. There was also a significant increase in excellent knowledge on the sources of vitamins and a significant decrease in the use of vitamin/tonics after the intervention. CONCLUSION: The participation of intermediary groups eg. school teachers, journalists and school children in the implementation of intervention were successful. The groups have fulfilled the commitments in implementing the plan of action. The key messages have effectively reached the households, and the knowledge and practices of the community members in drug use have improved.

An intervention improving prescribing practices and monitoring drugs availability in a district.

To improve the quality of health care in Nepal, supervision/ monitoring involving periodic visits by the district supervisor to health facilities (top-down approach) is in practice. It is not objectively implemented because of time and financial constraints and terrain of the country. To assess the effectiveness of a pre-tested strategy i.e. peer-group discussion with self-assessment piloted through the district health system in improving quality of care. A pre-post pilot study was conducted in 41 PHC facilities of Chitwan district of Central Nepal. The intervention included small-group training to prescribers followed by peer-group discussion with self-assessment data. It involved visit of in-charges from health facilities to district level regular meeting with self-assessment data on the treatment of four targeted health problems and also the availability of drugs of their health facilities as well as from health facilities which were under their supervision (bottom-up approach). In under-five children, there was a significant improvement in use of antimicrobials in diarrhoea, paracetamol alone and antibiotics in no pneumonia, and co-trimoxazole or amoxycillin alone or with paracetamol in pneumonia. The use of benzyl benzoate or gamma benzene hexachloride alone and antibiotics in scabies were also significantly improved. The peer-group discussion, a bottom-up approach of supervision/monitoring implemented through district health system improves the prescribing practices and availability of drugs in the district.

Strengthening emergency obstetric care in Nepal: The Women's Right to Life and Health Project (WRLHP).

INTRODUCTION: The Women's Right to Life and Health Project contributes to Nepal's National Safe Motherhood Program and maternal mortality reduction efforts by working to improve the availability, quality and utilization of emergency obstetric care services in public health facilities. METHODS: The project upgraded 8 existing public health facilities through infrastructure, equipment, training, data collection, policy advocacy, and community information activities. The total cost of the project was approximately US$1.6 million. RESULTS: In 5 years, 3 comprehensive and 4 basic emergency obstetric care (EmOC) facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9 to 16.9%; the proportion of births in EmOC project facilities increased from 3.8 to 8.3%; and the case fatality rate declined from 2.7 to 0.3%. DISCUSSION: While the use of maternity services is still low in Nepal, improving availability and quality of EmOC together with community empowerment can increase utilization by women with complications, even in low-resource settings. Partnerships with government and donors were key to the project's success. Similar efforts should be replicated throughout Nepal to expand the availability of essential life-saving services for pregnant women.