ISQUA18-2587Equity of Pediatric Patient care in Ambulatory Primary Healthcare Clinics in Cambodia

Abstract

Objectives: To determine the effect of quality improvement and social audit mechanisms on equity of pediatric care in rural ambulatory clinics in Cambodia Methods: WHO and UNICEF conceptualized the integrated management of childhood illness (IMCI) clinical practice algorithm to address the major disease burden in children under five, especially for contexts with extreme resource constraints, which lack adequate clinicians. The guidelines have been adopted by over 100 countries, but empirical assessments have indicated myriad barriers for the optimal implementation of the guidelines especially in rural settings. In the recent years, Cambodia has launched several systems strengthening strategies to ensure system readiness at the clinic level, health insurance schemes for equitable access to quality care, and health management committees to facilitate social audits of performance and community engagement. We conducted an appraisal of all primary healthcare clinics in the public sector in four districts- /sub-districts; Chulkiri, Pouk, Prasath Balang, Tbeng Meanchey. Additional interventions of community voice and action including community scorecards were integrated into the programs instituted by the government of Cambodia in two of the selected districts. Two other matched districts received routine interventions. Five children under five were sampled randomly based on patient volume in each clinic and trained teams performed observations of clinical encounters followed by child caretaker exit interviews. Quality of care was defined as adherence to the IMCI clinical standards for patient screening and counseling. Results: Nine clinics were included in the final sample with 45 outpatient visits for children under five. The major presenting complaints were those addressed by IMCI; diarrhea (18.2%), fever (52.3%), and cough or difficult/rapid breathing (22.7%), with 100% reporting comorbidities. The quality of patient screening, defined by an index of IMCI screening standards was significantly higher in the clinics receiving additional social audit interventions than those that received routine systems strengthening interventions (IMCI screening index 8.8 vs 7.00, p < 0.05). The counseling index, was also significantly higher for caretakers for clinics receiving social audit interventions (IMCI counseling index 3.1 vs 2.1, p < 0.01). Linear regression models showed that IMCI screening and counseling were significantly higher with the social audit intervention (IMCI screening index 1.833, p < 0.01, IMCI counseling index 1.000, p < 0.001). However, multilinear regression modeling controlling for selected patient-provider characteristics; child age, child sex, presenting complaint, child caretaker educational status, and health insurance, illustrated no significant effect of social audit interventions on screening quality. Factors significantly associated with IMCI screening quality were consultations conducted by assistant doctors (1.510, p < 0.05), screening by IMCI trained providers (2.885, p < 0.01), consultation time (1.072, p < 0.05) and children from wealthier quintiles (2.834, p < 0.01). Conclusion: Cambodia has made considerable investments to enhance equitable coverage and quality through multiple systems strengthening and community engagement strategies. Despite limitations of small sample size, the study provides some key insights to continue efforts for IMCI training, staffing of primary clinics with assistant doctors, and address wealth inequities in quality of care.