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Jan 26, 2019

Minimum Service Standard (MSS) - a stepping stone for Quality Health Service in Nepal (Post 23/24)

Quality of Care (QoC) is currently a hot topic not only among health professionals but this is a national agenda that has touch upon the life of every family in Nepal. True, when we are not feeling well or injured, we have to visit the health center and we expect a decent level of care. With this thought process, every leadership at the Ministry of Health (MoHP) have put on an effort to bring quality health service to the people. Accordingly, the Policy on Quality Health Services, 2064 in its annex has the operational definition of quality health services as “ that produces desired health outcomes and fulfill consumer needs with optimum use of available resources provided by trained and competent providers as per national norms and standards with minimizing risk for providers as well as consumers.” Most recently, the National Health Policy (2071 BC) has envisioned “A provision to provide quality health service as a fundamental right of the citizens shall be ensured.”, which is one of the key principles that guide the National Health Sector Strategy (2015 - 2020). And to stress here again, the issue of quality health services has become the burning issue and the most talked about everyday news headline. Sadly, the flood of negative headlines in the media have caused so much distrust in public health care services, be it private or public, within Nepal.

In this light, let me share an excerpt from “The epidemic of poor-quality care” which is easy to relate with our current health delivery challenges in terms of difficulty providing quality of health care services to all people. It says, “the over 8 million excess deaths due to poor quality health systems lead to economic welfare losses of US$ 6 trillion in 2015 alone. The Commission found systematic deficits in quality of care in multiple countries, across a range of health conditions and in both primary and hospital care. These include: Approximately 1 million deaths from neonatal conditions and tuberculosis occurred in people who used the health system but received poor care. Poor-quality is a major driver of deaths amenable to health care across all conditions in LMICs, including 84% of cardiovascular deaths, 81% of vaccine-preventable diseases, 61% of neonatal conditions and half of maternal, road injury, tuberculosis, HIV and other infectious disease deaths. Insufficient access to care was a proportionally greater contributor to deaths from cancer (89%), mental and neurological conditions (85%), and chronic respiratory conditions (76%), highlighting the need to increase access to care for these conditions alongside improving quality. Data from over 81000 consultations in 18 countries found that, on average, mothers and children receive less than half of the recommended clinical actions in a typical visit, including failures to do postpartum check-ups, incorrect management of diarrhea or tuberculosis, and failures to monitor blood pressure during labour. A third (34%) of people in LMICs report poor user experience, citing lack of respect, long wait times, and short consultations. Similarly, confidence and trust in health systems are low. For instance, in India, half of the households report bypassing their nearby public facility, with 80% citing at least one quality concern. Poor-quality care is more common among the vulnerable in society. The wealthiest women attending antenatal care are four times more likely to report blood pressure measurements, and urine and blood tests compared to the poorest women; adolescent mothers are less likely to receive evidence-based care, and children from wealthier families are more likely to receive antibiotics. People with stigmatized health conditions, such as HIV/AIDS, mental health and substance abuse disorders, as well as other vulnerable groups such as refugees, prisoners and migrants are less likely to receive high-quality care.”

In Nepal, there is a serious effort put into exercise to improve the quality of care in Nepal. For this, there is a new paradigm or an approach of Minimum Services Standard (MSS) has been implemented and now, it is being scaled up all the over the country.  In its implementation, there are 3 key area of focus: (1) Governance and management  (2) Clinical Service management and (3) Hospital support system management. In a way, MSS can be taken as quality improvement (QI) tool, which is a part of hospital management program with 8 major areas: (1) Governance (2) Organizational management (3) HR management (4) Financial management (5) Information management (6) Quality management (7) Clinical management (8) Hospital services. This is also an evaluation tool, which is used for the regular periodic assessment. However, there is one burning question being asked everywhere is, “how do we motivate the hospital team to sustain MSS practices? Our experiences say that some hospitals are utilizing this MSS as a management tool with the greatest enthusiasm and have brought a remarkable change in service delivery, while some hospital team are either not that motivated or least bothered and taken as an additional burden to their daily activities. Anyway, ups and downs are the usual stories in the introduction of the noble effort of the good of the public services. With time and learning, every hospitals and clinical team will adopt it into their core hospital practices as a routine activity. In order to push this momentum forward, MoHP is simultaneously developing an implementation guideline for MSS.

Also, we need to understand that the issue of QoC is not only our national issue but this is a global issue where poor quality of care is taken as a threat to efficient and social justice. Therefore, this issue of QoC is an essential function of all government from federal to provincial to the local level. In this respect, all the governance structure for hospitals, there should not be compromised in the quality of recording reporting and recording of services provided along with robust M & E function built within that is coordinated at all levels. Therefore, the role and responsibilities of each level of govt need to be loud and clear and communicated well in advance in writing. So, hospital strengthening and standards improvement should be an important activity and targets in annual policy review as well as program planning and budgeting.

Another point that is often raised and discussed in a various forum is that “fragmented or duplicated  health care delivery and its implementation is a key challenge that we need to address." So, what it means is that there are various different quality frameworks as well as tools being used for a long time through various programs within DOHS. It is therefore high time that we create a single quality of care framework under which all quality related tools or approach has to be integrated so we will be able to integrate the information system ( which is also fragmented !!) under one roof of M & E action plan. This will help MoHP in reducing the confusion, resource wastage and save us from failure or underperformance of many programs so all programs will run in the best interest of our people.  

Not to forget, whatever tools for implementation are introduced after we need to consider in all seriousness the sustainability of it, whether MOHP has all the capacity and resource to maintain and scale it up all over the country? In its elaboration, there are some measures taken by MOHP for in-service quality assurance for healthcare providers and plans for health service accreditation process. For this initiative, all the professional bodies like NMC, Nursing Council, NPHC and Ayurved Council have a major role in in-service quality assurance. We need to clarify upfront that MOHP alone cannot be responsible for all these process and procedures. And for that reason, there are various councils, academic institutions, and research centers.  In nutshell, the provision of quality health care services has to be everybody’s business and national effort.

Anuj in Himalayas

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