The association of health workforce capacity and quality of pediatric care in Afghanistan

Abstract

Enhancing workforce capacity and competency and ensuring appropriate supervision and systems support mechanisms can contribute to improved quality of care. Although the results indicate sustained improvements over the study period, further research on the mixture of provider skills, competency and factors influencing provider motivation are essential to determine the optimal workforce capacity in Afghanistan.

Long and short Integrated Management of Childhood Illness (IMCI) training courses in Afghanistan: a cross-sectional cohort comparison of post-course knowledge and performance

“…Although this number was small, the observation could stimulate the question of how many other health workers in Afghanistan retain knowledge and practice from previous 11-Day trainings. This finding is in line with that of the IMCI Working Group in 2007 which revealed low IMCI implementation amongst previously trained health workers (almost exclusively doctors) but it differs from larger cross-sectional studies that have demonstrated some benefit of previous IMCI training on quality of care (9,10,17). The 7-Day trainees classified fever as malaria less often than the 11-Day trainees (47% versus 71%), an observation that could have resulted from a difference in malaria incidence in the region during the two month period of the evaluation or due to the fact that the 7-Day course algorithm for fever was stratified into high incidence and low incidence areas.…”

“…The fact that non-physicians performed less well in the counselling score is surprising in light of the literature and additional research would be necessary to elucidate this further (21). Previous studies in Afghanistan have also identified that female health workers performed better in counselling and providing quality care to children, findings not substantiated by this evaluation (10,19). In this evaluation, two physicians in the 7-Day group and three physicians in the 11-Day group had previously completed an 11-Day IMCI course, yet when these five doctors were excluded from outcome variable calculations, minimal differences in test scores and in summary variable scores were demonstrated.…”

“…Were the 7-Day course to be adopted in Afghanistan, the importance of ensuring adequate emphasis of the concepts in the fever module must be stressed to avoid underclassification of malaria. Several advantages of using the shortened course include: a) the ability to train more health workers in settings like Afghanistan where turnover of trained health workers is common; b) reduced cost of training per health worker in countries that rely on external funding for healthcare, (a 36% cost savings was projected per course given in Afghanistan, findings substantiated in Zambia, Uganda and Kosovo) (13); and c) the possibility to re-allocate resources to provide supervisory visits, an activity that this evaluation and others suggest can maintain the long-term benefits of shorter IMCI training courses (9,10,20). In addition, shortening the course responds directly to requests of NGO health workers who implemented IMCI in rural and remote settings where health workers have expressed difficulties in taking courses that last 11 days.…”

“…The primary problems identified by the working group were similar to issues identified in other countries: insufficient numbers of health workers were trained in IMCI and there was high attrition amongst those trained (8,18). Previous assessments of the quality of care provided in the Afghan primary health system have highlighted several additional influences on quality of IMCI implementation: availability of doctors, having ever received standard IMCI training, short appointment times for patients due to large patient volumes, and factors such as provider job satisfaction, availability of clinical guidelines, frequency of supervision and the presence of community councils (9,10,19,20). In Afghanistan 71% of IMCI trainees were physicians when the more common types of health workers who provided services to sick children were midwives, nurses and community health workers (17).…”

Use of clinical guidelines: perspectives from clinicians in paediatric and maternity hospitals in Kabul, Afghanistan

“…Afghanistan ranks 175th (out of 185 countries) on human development index (HDI) rankings, with one of the highest child and maternal mortality rates globally (under-5 mortality 64 per 1000 live births; maternal mortality ratio 327 per 100 000 live births) (16). Health workforce capacity is at one-third of WHO recommendations (7.26 doctors/nurses/midwives per 100 000 population) (17,18) and poor quality of care is impairing progress in maternal and child health (19,20). Professional and pharmaceutical regulation is weak, research capacity and access to evidence is severely limited, and large gaps remain in health service management, broader social support systems and infrastructure (17).…”