Effecting Change with Cross-Cutting Interventions
So far this chapter has outlined concepts fundamental to understanding the position, functions, and performance of the district hospital and has presented some of the existing (though limited) data on costs and cost-effectiveness. Operating at the interface between primary care—aimed often at the poor—and the more Western biotechnological model of care at secondary and tertiary levels—often more accessible to the better off—district hospitals are easy to ignore because they lack any advocates for their role. However, optimizing their role to maximize health benefits and promote equity does demand the following:
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explicit policy decisions about the services that should be offered at this level and about the balance between primary care, district hospital care, and higher-level care services provided
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national strategies on the distribution of services that encompass all providers
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commitment to provision and equitable distribution of essential human resources and supplies
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systems for monitoring hospital performance in terms of efficiency and quality and for intervention when performance is poor.
When a framework defining the district hospital is available, interventions that might improve performance can be considered. The focus here is on cross-cutting interventions rather than condition-specific or service area-specific interventions described elsewhere. Cross-cutting interventions seem to be rarely prioritized but have the ability to add value in many areas and are perhaps critical when thinking of developing an improved health system.
Human Resources
Key issues that affect district hospitals are the quantity and quality of personnel and their range of skills. Staff members should be appropriate to the tasks they are asked to perform. This approach may mean continuing to use nursing or auxiliary staff members with more limited training in district hospitals because they may be more cost-effective, running against the tide of rising academic requirements often demanded by professional associations (AED 2003). Similarly, devolving some tasks to lower cadres of staff may be practical and much more efficient—for example, training and licensing clinical assistants to perform emergency surgery including cesarean section. Such initiatives, too, may face opposition from powerful professional vested interests. Although some tasks may be transferred downward, a problem often faced by district hospitals is an absence of high-quality senior staff members or leaders. Traditionally, running a district hospital has commanded less respect and remuneration than work at a secondary or tertiary facility and has been regarded as a stage to be moved through as rapidly as possible. Arguably, the challenges to a district hospital professional are at least as great as those of a tertiary consultant specialist, and the development of appropriate skills-training programs, and parity of postgraduate qualifications and pay, might help foster the development of a professional group that improves performance and fills a much needed advocacy role.
Improving Clinical Management
For more than a decade, industrial countries have increasingly promoted the use of the best evidence in clinical management. Clinical guidelines, means to implement them, feedback on their use and value, clinical audit, and performance review are all now the subject of considerable research, with some evidence of benefit particularly when part of a broadly based approach (Grol and Grimshaw 2003). District hospitals in developing countries have largely missed out on this revolution, which may be of particular value in settings where care by nonspecialists with little or no access to recent information is the norm.
Information and Integration
Although much focus is given to technological development in the fields of diagnosis, treatment, and imaging, relatively little attention is paid to the potential for technology to change the collection and use of information, despite the possibly major effect on improving administrative and clinical management. As at the primary care level, where many of the interventions are currently available to achieve significant reductions in mortality (Claesen and others 2003), many of the tools that could be used to improve health are well known at the district hospital level. Making better use of these tools through more reliable provision, better training, improved information collection, on-the-spot analysis of data, and real-time use of the results for service planning might be both possible and of considerable benefit (Cibulskis and Hiawalyer 2002). Clearly, how a hospital is performing as part of an integrated primary care system is also vital. Local information on population health, on use and referral patterns, and on success and the reasons underlying successes and failures is invaluable if the hospital is to respond to the particular needs of its locality.
Quality Improvement and Accreditation
Quality improvement is a generic technique adapted from industry that involves a rolling approach to identifying problems, solving them, and assessing the results of change (see figure 65.3) and that has been institutionalized in hospital care in many developed countries (DiPrete-Brown and others 1993). An essential first step is defining standards for service provision, which can span all areas, including the technical content of care, the physical environment in which care takes place, and interpersonal relations between patients and health workers. This approach is often linked to formal systems for external assessment of hospitals' performance and accreditation. Accreditation may serve as a goal for participating hospitals, a means of promoting positive competition, and a means of identifying poorly performing institutions. Potential advantages of such initiatives are empowerment of local service providers to solve problems they feel are important and the overall aim of working toward a systemwide standard of care. However, although an obvious need exists for quality improvement in hospitals in developing countries (English and others 2004b; Nolan and others 2000), few examples exist of hospital-level interventions in industrial or developing countries that provide evidence of effect on major outcomes. One exception is a broadly based quality improvement intervention targeting maternal and child health in Peru that focused on the entire system of care. This project was associated with a 25 percent decrease in maternal deaths in program areas (see box 65.2 for details). However, the relatively poor progress of an operational-level quality improvement and accreditation program in Zambia's hospitals highlights the significant problems of intervening in countries with poorly functioning health systems that are severely constrained by lack of resources (Bukonda and others 2002).
[Figure
65.3]
[Box 65.2]
Hospital-acquired Disease
Probably the most important infection in developing countries that can be acquired as a result of hospital care is HIV, especially in Sub-Saharan Africa. Reuse of needles and blood transfusion are the main sources of infection and also carry the risk of hepatitis B and C and other viral infections important in their own right. It has been estimated that effective measures to improve blood safety in particular are a highly cost-effective intervention at approximately US$8 or less per DALY (Creese and others 2002).
Nosocomial infection, another major adverse consequence of admission to hospital, is common in some settings in industrial countries, contributing significantly to hospital costs. Historically, relatively simple approaches to prevention have proven reasonably effective with additional effect from dedicated prevention services (Ayliffe and English 2003). The potential effect of intervention in district hospitals in developing countries is largely unknown, although in China nosocomial infection rates of between 8 and 13 percent have been reported (Barnum and Kutzin 1993). Because overcrowding and lack of basic resources, even water, are common in some districts, the potential for simple cost-effective interventions to prevent such infections seems high.
Other Managerial Initiatives
In high-income countries, numerous other initiatives are being tested to promote improved efficiency and quality. They often rely heavily on having in place appropriate institutional arrangements, managerial capacity, and information systems, so their feasibility for local implementation is highly dependent on local circumstances. One of the most widely tested arrangements within public national health systems has been the experiment with internal markets, in which a range of public hospitals compete for contracts from separate public service purchasers, such as local governments. The split of purchaser and provider of public services is recognized as a potentially powerful instrument for securing efficiency improvements but can be demanding in terms of managerial skills (Le Grand, Mays, and Mulligan 1998).
A less direct way of introducing some form of competition into the hospital market is to require hospitals to publish performance reports that allow direct comparisons to be made between hospitals.
An alternative to relying on indirect methods of influencing behavior is to give physicians incentives or instructions to deliver care in line with guidelines reflecting best practice. In the United States, numerous experiments have been carried out under the general banner of managed care (Glied 2000), and other systems have attempted analogous approaches to hospital regulation. At one extreme is the centralized U.K. system of performance management, under which hospitals are given challenging and immediate targets and are rated according to measured outcomes (Smee 2002). At the other extreme is the system of guided self-regulation practiced in the Netherlands, under which hospitals are required to engage in quality improvement but are given no prescription as to what format that effort might take (Klazinga, Delnoij, and Kulu-Glasgow 2002).
