Class Research Works and Seminar Papers

Health care quality assurance in Ghana

I. INTRODUCTION

Background

Sub-Saharan Africa was especially hard hit during the severe economic downturn that affected many developing countries during the 1980s and early 1990s. In many countries, the health sector was buffeted by a range of stresses: Non-wage expenditures (especially those for drugs and maintenance) and real salary levels stagnated or declined, demoralizing health sector staff and diminishing the quality and use of health services. There was a loss of public confidence in the health system. At the same time, the effects of the epidemiological and demographic transitions, the resurgence of diseases such as tuberculosis and malaria, and the emergence of such new diseases as HIV/AIDS multiplied the pressures on the already weakened health systems.

In response, a number of African countries embarked on efforts to reform and revitalize their health services. Primary elements of these efforts included decentralizing authority to the district level; reorganizing and integrating health care delivery to provide universal access to a minimum package of essential services; improving the supply, use and management of essential drugs; improving the financing of health sector reform through better donor coordination; and instituting community financing and co-management of health services. Evaluations of these national health sector reform efforts have concluded that, though many challenges remain, a number of national programmes have succeeded in raising coverage, improving quality and increasing the accessibility of health services. Foremost amongst these countries was Ghana.

Studies have been conducted severally on Ghana healthcare sector especially the Primary Healthcare because in 1976 a very in-depth study of its primary healthcare infrastructure was carried out and was called The DANFA Project with the assistance of United States Agency for International Development (USAID). This at least gave some notable yardsticks and information to guide other studies like the case of quality assurance discussed here.

Introduction to Quality Assurance in Ghana

Concerned about low utilisation levels and poor quality of government health services, the Ministry of Health in Eastern Region has been investigating quality of care issues since 1992. A series of research studies have identified the factors affecting quality of care according to patients and shown that their concerns are not adequately addressed at hospitals and health centres in the region. Many of the quality factors identified can be improved by health personnel WITHOUT extra resources.

In 1994 a set of quality indicators was developed which could be used to monitor quality of care in the region. These were tested in 4 facilities and found to be valid, reliable, sensitive to variations in quality, and feasible for health staff to measure. If a health facility performs well on these indicators, it will almost certainly be satisfying its patients. Monitoring with these indicators can thus help health personnel to make their services more responsive to client's expectations and improve utilisation.

It is likely that people in the other regions of Ghana share the same concerns regarding quality of health service delivery.

This manual is targeted at hospital, clinic and health centre staff, to raise awareness about the importance of quality assurance in every day work situations. It describes how to plan and establish QA at facility level so that it becomes part of the routine health care delivery system. This programme of QA training has been purposely designed for institutions, since direct improvements in the quality of patient care can only be realised by the direct providers of care (those who make the decisions with and on behalf of the patient). Therefore by focusing on both hospital and clinic personnel this programme will promote local ownership for quality assurance and it should have a considerable impact on the quality of health service delivery. Since health care delivery is based on team work, this QA approach supports a multi-disciplinary team approach for working on quality related problems (this approach has proved to be highly effective in the pilot programme).

The manual should be used as an aid for facilitators and participants in organising quality assurance workshops and activities and can also be used as a management tool for those unable to attend. Mindful of the disruptions that occur when taking personnel off-site for training, the duration and location for each workshop has been taken into consideration. Thus this training programme is divided into 2 stages of 3 days each with implementation phases after each workshop. It is also suggested that training should be zoned to minimise disruption to normal working duties.

The Quality Assurance Process

The main common assumption behind national and international QA initiatives is that QA activities are good for the system; they help to increase effectiveness and efficiency and to control costs. The essence of any QA approach involves the measurement of actual performance and its comparison with expected performance and the implementation of changes to improve the delivery of health services and, consequently of health status. However, there is no single, well experienced answer as to how to implement QA as a routine function in health care delivery organisations. The indicators developed in Eastern Region provide a tool, appropriate to the Ghanaian context, for setting standards, measuring and improving quality. This process also focuses it attention to internally caused and solvable problems. This mechanism can now be used to initiate the QA process in Ghana.

Stages in the QA Process

This training manual provides all the necessary information and materials to run a two stage QA training programme interspersed with two implementation phases. Up till now training has largely been targeted at District Health Management Teams, Hospital Management Teams and Sub-district Health Teams with less attention on institutional teams, especially at sub district level. For many staff it will be the first time they have attended such a session since their formal training. The most crucial part of this workshop is that staff leave with the confidence and necessary knowledge and tools to go back into the field and initiate the QA process in the work place. At the end of each stage staff will be able to commence the following activities:

Stage I

establish a multi-disciplinary Quality Action Team in their institution
increase staff awareness about the importance of Quality Assurance
initiate the process of monitoring patient defined indicators, including data collection, analysis and interpretation
use this information as a QA tool to aid local decision making and encourage a multi- disciplinary, teamwork approach in solving problems relating to quality of health service delivery.

Stage II

assess progress made since the implementation of the initial quality checklists
incorporate lessons learnt into developing more effective strategies and improved plans for the next 6 - 9 months
strengthen skills in problem identification, analysis and solution
stimulate QA awareness in other areas of the hospitals and clinics by also considering professional quality factors

After this 2 stage training and implementation process, institutions will have reached a state whereby the QA system will have become part of the routine health care delivery system. It should take approximately 1 year to reach this state.

QA Roles at Different Levels in the Health System

A quality system defines the roles, responsibilities, processes and procedures within the organisation in order to ensure that staff are able to and do carry out quality assurance activities. This should be defined from National down to Institutional level so that every part of the organisation is accountable for and involved in the QA process. It is important to note that the district level has been defined as hospitals and sub-district as health centres because implementation of the pilot QA programme has been driven directly through the health facilities which are the front end of health care delivery.

National Level:

The role of national level is to facilitate and direct regions in how to establish QA systems. This can be achieved through a national level QA steering committee, which should be an integrated rather than a vertical structure since QA permeates into every area of the health system. This committee will serve as a resource to regions by:

defining quality of care
co-ordinating country-wide QA efforts
producing a broad (flexible) set of QA guidelines
setting national standards (to be used and adapted by regions)
monitoring a small set of quality indicators relevant to all regions (eg maternal mortality, bed occupancy rates, waiting time in OPD, wound infection rates etc)
allocating adequate QA resources to the regions

Regional Level:

Regions have a crucial role in QA. It is this level which should be responsible for the co-ordination and monitoring of QA implementation in the districts and sub-districts. This is achieved by establishing a QA monitoring team to serve as a resource for institutions by:

providing co-ordination, guidance and regular feedback to districts, sub-districts and institutions
organising QA workshops and seminars
training and facilitation during workshops and seminars
ensuring supportive supervision to health institutions
monitoring institutions
encouraging high performance by comparing institutions and promoting best practice
adapting national standards and guidelines to suit regional needs
developing regional standards
allocating QA resources to institutions

District (Hospital) Level:

At the hospital level it is vital that each facility establishes a multi-disciplinary quality action team which will be responsible for implementing QA and will serve as a resource to the rest of the hospital by:

providing co-ordination, guidance and information to hospital heads of department and the hospital management team
promoting QA awareness hospital -wide
monitoring performance of wards and departments
analysing and using QA data at facility level
identifying quality problems and drawing up quality action plans
co-opting other health professionals to work on QA
implementing quality action plans
producing/adapting/updating relevant local standards/guidelines/protocols
ensuring in-service training is provided where necessary

Sub-District (Health Centre) Level:

At health centre level it is vital that each facility establishes a multi-disciplinary quality action team which will be responsible for implementing QA and will serve as a resource to the rest of the facility by:

promoting QA awareness
monitoring performance of the health centre
analysing and using QA data at facility level
identifying quality problems and drawing up quality action plans
co-opting other health professionals to work on QA
implementing quality action plans
producing/adapting/updating relevant local standards/guidelines/protocols
ensuring in-service training is provided where necessary

For the aforementioned work ,This Quality Assurance manual was written and field tested by:

Eastern Regional Health Administration, Ghana, and
Liverpool School of Tropical Medicine

Contributors:

Dr Aaron Offei
Dr Ken Sagoe
Mrs Evelyn Owusu- Acheaw
Miss Vicki Doyle
Dr Dave Haran

This Quality Assurance manual has been specifically developed for the Ghanaian context and has been written for hospital, health centre and clinic staff. It is the result of 3 years of extensive research carried out in the Eastern Region, Ghana in response to the need of providing more patient focused health services. The materials have been tested in 2 districts; in Kwahu South district at Kwahu Government hospital (Atibie) and Holy Family Hospital (Nkawkaw), and in Birim North district at New Abirem Health Centre and St Michael's Clinic (Ntronang). Both Government and Mission facilities have purposely been involved from the start, since to exclude any organisation from the Quality Assurance process could have serious implications for health service provision in Ghana. In the earlier stages of this research Koforidua Central Hospital, St Joseph's Hospital, Achiase, Akim Swedru, Bososo and SA Begoro health Centres were also involved. Many thanks go to all these institutions, for their enormous enthusiasm and support for this Quality Assurance initiative.

REFERENCES

Berman, Peter (1995), ‘Health sector reform: Making health development sustainable’,

Health Policy 32(1-3):13-28.

http://www.liv.ac.uk/lstm/qainfo.html

Cassels, Andrew (1995), ‘Health Sector Reform: Key Issues in Less Developed Countries’

(Geneva: World Health Organization, Forum on Health Sector Reform Discussion Paper No.1).

Galland (1997), The problem of equity of access to health: Exclusion of people in highly

precarious situations (New York: Bamako Initiative Operations Research Programme,

Research Paper No. 3, UNICEF).

Knippenberg, R., Reinke W, and Hopwood, I., eds. (1997), ‘Sustainability of Primary Health Care

including Immunizations in Bamako Initiative Programmes in West Africa: An Assessment of

5 Years’ Field Experience in Benin and Guinea’ (special issue), International Journal of Health

Planning and Management 12 (suppl. 1).

Knippenberg, R., et al (1997), ‘Implementation of the Bamako Initiative: Strategies in Benin and

Guinea’, International Journal of Health Planning and Management 12 (suppl. 1):S9-S28.

Nwe, Yin Yin (1995), ‘Synthesis of Some Thematic Evaluations in West and Central Africa:

Lessons Learnt from Strengthening and Revitalization of Health Systems’ (UNICEF, Abidjan:

Regional Office for West and Central Africa).

Porter, Robert W. (1995), Knowledge Utilization and the Process of Policy Formulation:

Toward a Framework for Africa (Washington, DC: Africa Bureau, USAID).

Samake, Salif, Georges Dakono and Flavia Guidetti (1995), ‘La carte sanitaire, outil de négociation

pour le développement sanitaire: L’expérience du Cercle de Koulikoro’ (paper presented at the

International Conference on Innovations in Medical Practice and Health Financing in sub-Saharan

Africa, Bamako, Mali, February 1995).

Resistances to Behavioural Change to Reduce HIV/AIDS Infection, 1999, 35-39 Chapter 3

Barriers to sexual behaviour change after an HIV diagnosis in sub-Saharan Africa

Karla Meursing

Macfarlane Burnet Centre for Medical Research, Melbourne

Abstract

This longitudinal, in-depth study of sexual behaviour of 96 HIV-positive individuals in a sub-Saharan country where HIV is heavily stigmatized, showed that even with counselling and free condoms, most people with HIV did not succeed in maintaining long-term, consistent condom use. Their condom use depended on fluctuations in their health status, and the anticipated or actual reaction of their social environment. People with HIV encountered the same barriers to safer sex as the community in general: women's lack of sexual decision-making power; men's dislike of condoms; denial of HIV, especially in men; and child-wish. In addition, HIV-positive people who did not disclose their HIV status feared that proposing to use condoms would raise partners' suspicions, and lead to social rejection and stigma. Results suggest that HIV testing and counselling programs will only achieve prevention of secondary HIV spread when they are preceded and supported by strong measures promoting acceptance and openness with regard to HIV.

HIV testing, with or without counselling, is promoted as a means to prevent the spread of HIV in developed and developing counties. The underlying assumption is that knowing their HIV status will enable individuals to take measures to reduce or eliminate HIV risk to others.

This study provided an opportunity to investigate this assumption. Between 1991 and 1993, 96 persons diagnosed HIV-positive at a counselling clinic in Bulawayo, Zimbabwe, were asked to participate in a program of continuing counselling and support. The study aimed to increase understanding and information about the medical, social, economic, and psychological problems of people with HIV in order to strengthen support services.

The study was conducted in collaboration with the Ministry of Health and the Matabeleland AIDS Council, a non-Government AIDS service organization located in Bulawayo which provides information, care and support in Matabeleland. A full report of the study can be found in Meursing (1997).

Context of the study

Zimbabwe has one of the most severe AIDS epidemics recorded. Between 1991 and 1993, seroprevalence among pregnant women in Bulawayo rose from 17 to 27 per cent, and it continued to rise in subsequent years. Because there is good transport infrastructure, seroprevalence in rural Zimbabwe is often not much lower than in urban areas. In 1995, seroprevalence figures in some urban and rural sites in Masvingo province exceeded 70 per cent of pregnant women. Heterosexual spread is the main risk factor, so that many children born to HIV-positive parents are born with the virus or face an uncertain future as orphans.

36 K. Meursing

In recent years it has become clear that Botswana and South Africa are undergoing equally serious epidemics. A number of social, cultural and medical factors are believed to contribute to the rapid spread of HIV in Southern Africa, including (1) gender role expectations, specifically women’s low social status, men’s claim to have a right to free sexual expression, and a high value placed on fertility (Taylor and Stewart 1991; Bassett et al. 1992; Berer and Ray 1993; Njovana and Watts 1996; Ray, Gumbo and Mbizvo 1996); (2) migrant labour, poverty and women’s economic dependence on men (Bassett and Mhloyi 1991); and (3) an epidemic of sexually transmitted disease.

In Zimbabwe from the late 1980s there has been a continuing AIDS information campaign which was highly ambivalent: while the Ministry of Health issued public warnings about HIV, other ministries and political and community leaders kept aloof. Until 1991, the Government actively suppressed information about the spread of HIV in the area.

HIV education was strongly prescriptive and biomedical in nature and was mainly communicated through the mass media and one-way lectures. Though in the early 1990s most adults in Zimbabwe knew the basic facts about HIV, behaviour change remained limited and HIV and STD incidence continued to rise (Ministry of Health 1994). HIV remained highly stigmatized, related to promiscuity and prostitution and difficult to acknowledge at a personal level. Condoms remained unpopular as men feared loss of sexual pleasure. Major barriers for condom use among married couples were difficulties in discussing sex, the association between condoms and promiscuity, and reduction of fertility (Mbizvo and Adamchak 1991; Jackson 1992).

Method

Fifty-eight women and 38 men diagnosed HIV-positive at an HIV counselling clinic attached to the outpatient department of a large tertiary hospital in Bulawayo were invited to take part in the study program, which consisted of continuing counselling, access to home-based care and free medical care at the hospital outpatient department. Each client was carefully counselled before and after testing, where possible with their spouse, sexual partner or close relative, and informed consent was obtained. Clients could choose to hold counselling sessions at their home, in the hospital, at the Matabeleland AIDS Council or at another convenient place.

Participants’ ages ranged from 12 to 53 years. As usual in samples drawn from public health facilities, the great majority of patients had low socio-economic status. This group consisted of symptomatic teenage girls and adults, and asymptomatic women diagnosed because of a sick child.

Out of 96 clients 72 agreed to participate in the study program and did so for a period varying between two and 31 months, with an average of 15.5 months and between three and 26 contacts. There were 67 contacts with participants’ social contacts: family members, sexual partners or service providers, for example, traditional healers or social workers. Twenty-four clients participated in pre-test and post-test counselling but refused further counselling.

Counsellors transcribed each counselling session or contact, thus creating a confidential and highly detailed record of clients’ problems and coping strategies over time. The validity of the data was increased by the length and intensity of the contact between the patient and counsellor and in-depth knowledge of the patients’ home situation. The study design also made it possible to triangulate information from patients with information obtained from their social environment and medical records.

Data were analysed by an iterative process of coding and condensation, which allowed the emergence and quantification of main themes from patients’ narratives while simultaneously retaining the richness and originality of their accounts.

Resistances to Behavioural Change to Reduce HIV/AIDS Infection Barriers to sexual behaviour change in sub-Saharan Africa 37

Results

Transcripts of counselling sessions showed that with continued counselling and access to free condoms, most study participants took some measures to prevent HIV spread, such as reducing the number of sexual partners, temporarily abstaining from sex or some-time condom use. Most married participants disclosed their HIV status to their spouses, which opened up the way for partner testing and co-operation to prevent infection. However, in non-marital relationships such disclosures remained rare.

Main motivations for condom use were to prevent the spread of infection, and to protect oneself against STD. Many participants were highly motivated to avoid STD as they were familiar with painful, persistent STD episodes. Nevertheless, long-term consistent condom use remained rare. Factors impeding consistent condom use were as follows.

Lack of hope, based on misinformation about HIV and fear of stigma

Many people with HIV and family members met the news of HIV infection with deep fatalism. This fatalism, which was difficult to dispel in counselling, was based on the belief that ‘HIV equals AIDS and AIDS equals death’, and on the expectation of universal social rejection. Many patients therefore experienced the prospect of disclosing their HIV status or introducing condom use as socially risky, with little to be gained.

Psychological avoidance

Very few study participants denied their HIV status completely, as most who denied their HIV status had dropped out of the study at pre-test or post-test counselling. However, participants’ acceptance of their HIV status fluctuated over time with changes in their health status. Periods of illness strengthened patients’ belief that the infection was real, and increased motivation for active coping strategies such as condom use. However, when symptoms improved many people pushed thoughts of their HIV status aside or even began to believe that they were cured, and motivation for condom use decreased. Such avoidance was fed by rumours in the community about available ‘miracle cures’.

Lack of co-operation from the partner

Wives who informed their husbands or partners that they had been diagnosed HIV-positive rarely received full support in coping actively with the infection. Many men had built up a habit of ignoring or denying HIV, and continued this habit once they knew their wife or child was infected. Men’s avoidance practices varied from refusing to be tested and refusing to discuss HIV, to aggression and abandonment of wife and children. Husbands’ aggression was a main reason for women not to participate in the study, as aggressive husbands had the power to bar their wives from contact with counselling services and to limit wives’ health-seeking options to health care providers unlikely to mention HIV, such as traditional healers or private doctors. Even in married couples who coped well together, husbands often remained reluctant to use condoms. As a consequence, condom use tended to decline over time or fluctuated with health problems in the family.

In non-marital relationships, women’s ability to prevent the spread of infection was limited by their economic dependence on their partners. Mature single women often had continuing relationships with married or divorced men based on an exchange of comfort and pleasure for material support. While mutual trust and intimacy in these relationships often was not sufficient for full disclosure of HIV, these mature women usually made concerted

Resistances to Behavioural Change to Reduce HIV/AIDS Infection 38 K. Meursing

attempts to persuade their partners to use condoms, as they feared STDs. However, many men reacted to these proposals with scorn, denial or threats to end the relationship. Women’s social and economic dependence on men meant that when partners were unco-operative, women were left with the choice of continuing the relationship without condoms, or breaking it off.

Fertility concerns

In relationships with hopes for marriage, disclosure of one’s HIV status to a prospective marriage partner was particularly difficult. Young single women in premarital relationships feared that proposing condom use would endanger their marriage prospects, as society expects brides to be keen to prove their fertility and their compliant nature. None of the teenage girls and few women in their early twenties felt confident enough of their relationships to disclose their HIV status to their partners.

Men in premarital relationships had similar problems, but were more able to introduce condoms temporarily without much explanation.

Because of the incompatibility of desire for marriage and disclosure with or without condom use, several young men and women started new relationships during the study period without taking any steps to protect their partners from HIV.

The consequences of unprotected sex were unwanted pregnancies, new STD episodes, and serious risk of HIV to sexual partners.

Conclusions

The problems clients encounter in using condoms are similar to the barriers encountered by the community around them. In Zimbabwe, this includes women's lack of sexual decision-making power, men's dislike of condoms, high value placed on fertility, and community denial of HIV. In addition, people with HIV fear that proposing to use condoms will raise suspicions of their HIV status and thereby increase their already immense load of problems by social rejection and stigma. Options and problems in introducing condoms differed with sex and type of sexual relationship, premarital, extramarital, and marital.

HIV testing programs should therefore not assume that knowledge of HIV status automatically enables individuals to take measures to reduce or eliminate HIV risk to others. Though counselling and support strengthen motivation and intention to use condoms, where secrecy and stigma prevail and where condoms are little accepted, knowing one’s HIV status may not be sufficient to achieve long-term consistent safe sexual behaviour. Once diagnosed, people with HIV continue to face the same barriers to safe sex as before diagnosis. In addition, they may fear that taking precautions will increase the risk of detection, stigma and rejection. Stigma reduces motivation to be tested and increases the likelihood that people will react to their HIV status by denial. Symptomatic individuals who practise denial are likely to avoid health and support services that may confront them with their HIV status, and may seek out health providers who will confirm their avoidance by giving a different diagnosis.

HIV education emphasizing the association between HIV and death promotes a view of HIV as a ‘death sentence’, increases denial and reduces the chance that people with HIV will feel ‘empowered’ to adopt active, positive coping strategies, including the use of condoms.

Programs for voluntary counselling and testing therefore need to go hand in hand with interventions that promote ‘living positively with HIV’ to the community as a whole, and address an existing community culture of stigma, denial and silence surrounding HIV.

Resistances to Behavioural Change to Reduce HIV/AIDS Infection Barriers to sexual behaviour change in sub-Saharan Africa 39

Recommendations

Condom use should be seen as one element of ‘positive living’. Hope and belief that active coping strategies will improve the quality and quantity of life of people with HIV and their families is crucial to engender motivation to cope actively with HIV. This necessitates unequivocal and widely publicized support, including personal messages, from Government and community leaders, for safe sexual behaviour and those infected and affected by HIV; reduction of stigma and avoidance by strong advocacy from Government, people-with-HIV groups, and public models of successful living with HIV; increasing women’s social and economic power and independence; interactive, creative HIV education which teaches ‘living positively with HIV’ for the community as a whole, avoids ‘AIDS kills’ as a central theme and enables men and women to see that challenging current sex role divisions is in their interest; and good services (including peer support ) after diagnosis, including medical, social and psychological support as well as material resources essential for ‘positive living’. HIV education and counsellor training should be culturally appropriate and gender-specific and include interventions for dealing with denial and avoidance. The development of such interventions should be supported by policy development and research.

References

Bassett, M. and M. Mhloyi. 1991. Women and AIDS in Zimbabwe: the making of an epidemic. International Journal of Health Services 31:143-156.

Bassett, M., A. Latif, E. Katzenstein and J. Emmanual. 1992. Sexual behavior and risk factors for HIV infection in a group of male factory workers who donated blood in Harare, Zimbabwe. Journal of Acquired Immune Deficiency Syndromes 5:556-559.

Berer, M. and S. Ray. 1993. Women and AIDS, an International Resource Book. London: Pandora Press.

Jackson, H. 1992. AIDS Action Now. Information, Prevention and Support in Zimbabwe. Harare: AIDS Counselling Trust.

Meursing, K. 1997. A World of Silence – Living with HIV in Matabeleland, Zimbabwe. Amsterdam: Royal Tropical Institute.

Mbizvo, M. and D. Adamchak. 1991. Family planning knowledge, attitudes and practices of men in Zimbabwe. Studies in Family Planning 22:31-38.

Ministry of Health, Zimbabwe. 1994. HIV and AIDS Surveillance Annual Reports 1990-1993. Harare: AIDS Control Program and Health Information Unit.

Njovana, E. C. and C. Watts. 1996. Gender violence in Zimbabwe: a need for collaborative action. Reproductive Health Matters 7:46-53.

Ray, S., N. Gumbo and M. Mbizvo. 1996. Local voices: what some Harare men say about preparation for sex. Reproductive Health Matters 7: 43-45.

Taylor, J. and S. Stewart. 1991. Sexual and Domestic Violence: Help, Recovery and Action in Zimbabwe. Harare: A. von Glehn and J. Taylor, in collaboration with Women and Law in Southern Africa.

Resistances to Behavioural Change to Reduce HIV/AIDS Infection 40 K. Meursing Resistances to Behavioural Change to Reduce HIV/AIDS Infection

HEALTH MANAGEMENT-II ASSIGNMENT OHANYIDO FRANCIS -MPH CLASS HEALTH MANAGEMENT II ASSIGNMENT What is Evidence Based Practice? Definitions of Evidence Based Practice There are a number of definitions of Evidence Based Medicine/Healthcare/ Practice. Below are reproduced some of those that are sited most commonly together with their source, where identifiable. The idea of Evidence Based Practice can only be well applied if its conceptual basis is well understood, and this can be looked at from two genres or sub-types ; the clinical and the broader medical concept. Evidence Based Clinical Practice • Quotation: "Evidence based clinical practice (EBCP) is an approach to health care practice in which the clinician is aware of the evidence that bears on her clinical practice, and the strength of that evidence". Source: http://hiru.mcmaster.ca/ebm/default.htm#What_is_Evidence_Based_Medicine (McMaster University) • Quotation: "Evidence based clinical practice is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best". Source: Muir Gray JA. (1997) Evidence-based healthcare: how to make health policy and management decisions. London: Churchill Livingstone. Evidence Based Medicine • Quotation: "Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer." Source: Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn't. BMJ 312 (7023), 13 January, 71-72). This paper is also available on the Web at: http://cebm.jr2.ox.ac.uk/ebmisisnt.html • Quotation: "Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients". Source: Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn't. BMJ 312 (7023), 13 January, 71-72). This paper is also available on the Web at: http://cebm.jr2.ox.ac.uk/ebmisisnt.html Evidence Based Healthcare • Quotation: "Evidence-based healthcare is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors." Source: First Annual Nordic Workshop on how to critically appraise and use evidence in decisions about healthcare, National Institute of Public Health, Oslo, Norway, 1996. • Quotation: "Evidence based health care promotes the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed, and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgements and facilitate cost-effective health care". Source: Evidence-Based Medicine Informatics Project Evidence Based Practice • Quotation: "Evidence-based practice (EBP) is an approach to health care wherein health professionals use the best evidence possible, i.e. the most appropriate information available, to make clinical decisions for individual patients. EBP values, enhances and builds on clinical expertise, knowledge of disease mechanisms, and pathophysiology. It involves complex and conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences. It recognizes that health care is individualized and ever changing and involves uncertainties and probabilities. Ultimately EBP is the formalization of the care process that the best clinicians have practiced for generations". Source: McKibbon KA (1998). Evidence based practice. Bulletin of the Medical Library Association 86 (3): 396-401. The process of Evidence Based Practice There are six cardinal steps in implementing EBP which are as follows in the healthcare setting - Problem Identification:- The information needed may be put forward in form of a question that will be answered. A problem is a situation that needs a solution. The problem is first identified and put forward in the form of a question in order to elicit the precise answers. A problem can emerge from a situation in which a knowledge regarding the best response to the situation exist. One has to constitute a multi-disciplinary team to develop a question. In a clinical setting for instance the team should represent all the key health care providers e.g. Medicine, nursing, pharmacy and nutrition. Adequate time must be allotted for this phase of the process so as to consider and develop the best and most appropriate question(s). Evidence Search:- This involves finding with maximum efficiency, the best evidence with which to answer the question(s). The evidence needed may be found from a variety of sources. It is usually time consuming to find evidence and it should therefore be systematic. All existing policies/procedures for current practice standard should be reviewed. Literature search/reviews should form part of the evidence search. Critique:- Evidence critique help in determining the merit, feasibility and utility of the evidence. Hence, it adds to its evaluation and serves as a basis for making a practical change. Synthesis:- In order to make a practical recommendation, there is need to take into consideration findings from all evidence. This is also best achieved by a multidisciplinary group. This could even be the original planning team/group. A person who has done synthesis work in the past should be part of the group. Synthesis requires practical and analytical thinking. Implementation:- This involves putting whatever is the recommendation into a practical work setting or organization. The problem is a coordinated, intentional and deliberate process. The process can be facilitated by planning, in order to prepare the organization for change. This will include data on the current practice, identification of stakeholders, determination of resources required for implementation of the change, identification of barriers and development of a time frame for education/re-orientation of staff among others. It may also be necessary to start with a trial implementation. Evaluation:- To determine the effectiveness of the practice overtime. Evaluation provides essential data for decision-making and assists in determining whether the intervention should be accepted, rejected or modified. In conclusion, It is a multi step, dynamic process that incorporates best external data and best judgment. Write short note on the "Diagnostic tree" A diagnostic tree is a functional representation of a system (in this case a health system) that is based on actual data , organisation, and characteristics that link the provider to the end-user , in other to analyze and interpret possible system failures or deficiencies. Diagnostic tree is to an extent an input into the process of planning. It is a problem tree aimed at mapping out core problems along with their causes and effects. This will assist planners to identify clear and meaningful objectives. The diagnostic tree is tripodal in arrangement:- - Roots - Trunk - Branches The trunk corresponds to the core problem. The roots represent the causes and the branches represent the effects of the problem. The cause of the problem may not be apparent. It is important to identify the causes of the problem and understand them as they form the basis for addressing any problem. Cardinal points for diagnostication and reform with the tree: 1. First, clarify your goals and values. 2. Diagnose the root problem--honestly. Draw the Diagnostic tree 3. Build health systems, not just medical systems. 4. Base your tree structure and plan on your nation's unique history, culture, and needs. DRAWING UP A PROBLEM /DIAGNOSTIC TREE In the wake of the Millennium Development Goals (MDGs) plan, wealthy nations have begun providing funds, technology, and training to help developing countries raise their levels of health, along with literacy, gender equality, and environmental quality. Thus there is increased tempo in global health structure re-appraisal and reforms leading to needs for use of diagnostication tools such as the diagnostic tree which has the inherent advantage of taking into consideration factors that are unique for the particular system being evaluated. It is undertaken involving all necessary stakeholders in order to achieve greater participation and holistic approach. Eg. Project coordinators, members of the communities and NGOs. The services require cards, pens, and sticky tape. - Identification of the Core Problem(s) You start by listing all negative statements of the project that describe the situation. Then write them on the cards and post on the wall. When it is completely sorted out you identify cards with similar statement and group them together. Thus by linking statements, a core problem is revealed. The next step is to examine other problems and find their relation to the core problem. This reveals them as either cause or effect with regards to the core problem. The cause and effects are then placed either above or below the core problem respectively and linked with arrows. Ultimately, a problem tree has been formed with relationship between causes and effects often in both ways. Finally the tree is copied onto a sheet of paper using lines and arrows to show the link between causes and effects. The problem tree then provides a good overview of the challenges facing the project, which can then be addressed. FIG.1Diagnostic tree for cause analysis of childhood malnutrition (Based on hypothetical data ) FIG.2.Diagnostic tree for cause analysis of maternal death in Iran (Based on the data adopted from national maternal mortality surveillance system (2001-2003) What is Efficiency? Introduction: Definition: It can be defined as doing something well and thoroughly without waste of time, money and energy (Advanced Learners Dictionary) Efficiency has to do with comfort and quality and also doing more with less. In whatever we do, efficiency comes into place, e.g. efficiency in production, energy, economy and health care delivery. Health Care Delivery Service Efficiency: Medical definition of efficiency by www.answers.com ef•fi•cien•cy (ĭ-fĭsh'ən-sē) n. 1. The production of the desired effects or results with minimum waste of time, effort, or skill. 2. A measure of effectiveness; specifically, the useful work output divided by the energy input in any system. The evaluation of the improvement of health care in relation to the resource required to produce them is what is referred to as efficiency in health care delivery service. The second major objective of health care delivery service is the drive for efficiency. Where health care is viewed as an output, the focus is on production efficiency (producing services at least cost) and where health care is viewed as an input, it is the product of health improvement with emphasis on allocative efficiency (maximizing health care delivery services with little resources). Allocative efficiency depends on the relative cost and effectiveness of medical and non-medical investment in improving health. Ultimately, maximization of health requires both productive and allocative efficiency. Efficiency promotes broad perspective grounded in relevant theory and research for assessing the performance of health policy and programmes and achieving the overall health care delivery service goals of quality, cost containment and access respectively. Efficiency is one of the criteria for the objectives of health care delivery. Efficiency in conjunction with effectiveness and equity are often complementary. Improving health care effectiveness while holding resources constantly. Increase in efficiency creates opportunity for improved effectiveness and equity. What is Equity? Definition: Equity can be defined as “The state, quality of being just, impartial and fair. To be fair requires both practical and ethical aspects. While equity has to do with justice which in turn has to do with lawfulness. However, it is worthy to note that equity and fairness cannot translate to all things. In general deciphering people on the concept of equity generates lots of disagreement as to who are equals and not, what to do about these differences. Government may treat people unequally or make health care services in such a way that affordability and accessibility could not be attained by all, equally. Types of Equity Equity can either be horizontal or vertical. - Horizontal equity:- this requires treating people the same with equal status by whatever measurement without ability or status. Hence people will pay the same amount to take and receive the same benefits. - Vertical equity:- here differences in ability of individual or group of people are taken into consideration, i.e. those with less ability are treated favourably than those with greater. - It is the opinion of some that horizontal and vertical equity is essentially application of the same principles. Another form of classification is into:- - Intergenerational equity - Intra-generational equity - Procedural equity - Consequential equity Intergenerational Equity:- It deals with the future generation and how they are effected by policy formulation and also by looking at temporal issues. Intra-generational Equity:- This looks at current distributional effects and examines how the policies decided upon today ultimately affect different countries and sectors e.g. the split between developed and developing countries centers on question of intra-generational equity. Procedural Equity:- It deals with process of negotiation and equity. Consequential Equity:- It deals with outcome, hence it is affected by politics and negotiating power.