Baby Input and Output and Process Tea Input and Output and Process
J Family unit Med Prim Care. 2015 Jul-Sep; iv(3): 352–358.
Evaluation of input and procedure components of quality of kid health services provided at 24 × 7 primary health centers of a district in Central Gujarat
Paragkumar Chavda
1 Department of Community Medicine, Gujarat Medical Education and Research Guild Medical College, Gotri, Vadodara, India
Shobha Misra
2 Department of Preventive and Social Medicine, Baroda Medical Higher, Vadodara, Gujarat, India
Abstract
Context:
With the critical Indian challenge on child survival and health, time is ripe to initiate focus on quality of services autonomously from measuring coverage, to bring most improvements.
Aims:
To assess the quality of kid health services provided at 24 × seven Primary Health Centers of Vadodara Commune in Gujarat in terms of Input and Process Indicators.
Settings and Design:
The report was carried out in 12 randomly chosen 24 × 7 Primary Health Centers (PHCs) of Vadodara district using a modified quality assessment checklist of the Program on Commune Quality Balls for Reproductive and Child Health (RCH) services with utilise of scores from May 2010 to June 2011.
Subjects and Methods:
Inputs assessment was done past facility survey. Process cess for the iv child wellness service components used actual ascertainment of service, review of records and interview of service providers and clients.
Results:
The mean obtained score for facilities in Input section was 65%. Highest score was obtained for Drugs and Consumables (86%) followed by Equipments and Supplies (74%). The score obtained for Infrastructure facility was 65%, Personnel and training was 56% and Essential protocols and guidelines scored 43%. The hateful obtained score in the process section was 55%. Highest scores were obtained for immunization at 76%. This was followed by newborn care (52%), growth monitoring (52%). direction of sick child (41%).
Conclusion:
Quality improvement efforts should focus not only on resource-intensive structural improvements, simply also on toll-effective measures at improving service commitment process, especially adherence to service guidelines by providers.
Keywords: 24 × 7 PHC, child wellness services, Gujarat, quality of health intendance
Introduction
India is faced with a disquisitional challenge in the area of kid survival and health. The refuse in Baby mortality rate has considerably slowed down in last two decades with the neonatal mortality beingness an emerging challenge.[1] Traditionally the wellness-care programs, including those on kid health, accept focused on the coverage of the services. Even so, improvement in kid survival and wellness would crave attention to the quality of services every bit well.
Lately programs systematically addressing quality of care have been piloted such as District Quality Assurance Program for Reproductive Health Services in Gujarat and Program on Quality Balls for District Reproductive and Kid Wellness (RCH) Services at the national level nether the Monitoring and Evaluation strategy of RCH Two.[ii,iii]
Although studies evaluating individual service components of child health program in different settings have been done in India, there are few studies on systematic assessment of Quality of Kid Wellness Services as a whole using a quality assessment framework.[4,v,6] Systematic assessment of the services uses scores to mensurate the quality every bit a whole and thus helps in program monitoring and tracking of improvements over a period of time. Largely, these earlier studies accept not covered the component of Newborn care at the Primary Health Centers (PHCs) which has get of import at present with increasing institutional deliveries.[4,5,half-dozen]
Hence at that place is a need to certificate the condition of the quality of comprehensive child health services provision. This report assesses the quality of kid health services provided at 24 × 7 PHCs of Vadodara District in Gujarat comprehensively covering newborn-care, immunization, management of sick child and growth monitoring services.
Subjects and Methods
The study was carried out in Vadodara District which is situated in the eastern-key part of Gujarat. The district is divided in 12 blocks (8 rural and four tribal). The District has a total of 76 PHCs. Of these, 29 PHCs are functioning every bit 24 × 7 PHCs (19 Rural and 10 tribal). A facility which is designated every bit a 24 × 7 PHC is one which is equipped for providing round-the-clock delivery services and new built-in intendance, in add-on to all the other emergencies that any PHC is required to cater to.[7] One 24 × 7 PHC, from each block, was randomly selected for the report. Hence a total of twelve 24 × 7 PHCs were included in the study sample. Study period was from May 2010 to June 2011.
This study used Donabedian Model for quality cess which is divided into three parts; Structure (Input), Process and Output.[8] Out of the three, this report has focused on Input and Process assessment. The ways of assessment of Output can be by assessing the changes in morbidity and bloodshed contour, utilization of services or in terms of patient satisfaction. This report has used the framework of the District Quality Balls for RCH Services Program.[three] Inside the program output has been defined equally modify in the utilization rates of services every quarterly over period of time. The scope of this study was just taking a cross-sectional view of the quality of services. Hence we accept been able to include merely input and process components. The tools for assessment were a modified form of the PHC Quality assessment checklists used in this Quality Balls Program, necessary modifications being fabricated after a airplane pilot study in two PHCs. Scores given to each of the items in the checklist ranged from ane to maximum 3 based on the relative importance of the particular. A high score (three) was given to the items which were considered very essential, a middle score (two) was given to those that were necessary, and a lower score (1) to those that were either less of import or were ane of the many components necessary for providing a item service. For example in input section the item on availability of a functional PHC vehicle (with driver) was given score of three because of its importance in transport of patients. If vehicle was bachelor simply driver was non available the obtained score on this item was considered to be zero for that PHC. The scores were added up at the end to get the total score for each sub-department. Weighted mean was used to arrive at the total department scores.
Inputs assessment
The Inputs cess was done by Facility Survey of the selected PHCs including physical verification of the availability and operation of items where needed equally explained below.
Provider's availability and training
This included interviewing the facility staff near availability of Medical Officeholder (MO) and the paramedical staff and their grooming.
Infrastructure
This included observation of the facility for maintenance of cleanliness and availability of physical infrastructure, bones civilities and information and communication services at the facilities.
Essential protocols and guidelines
This assessment included availability of guidelines on different kid health service components at the facility at the betoken of apply.
Equipments
This assessment included physical verification of the availability and functioning of the equipments required for the child health services.
Supplies of drugs and other consumables
This cess included concrete verification of the availability of the drugs and consumables for the kid health services.
Procedure cess
Divide checklists were used for process cess of the different components of Child Health services.
The checklist to study Newborn care component was based on the Essential Newborn Care Guidelines.[9] It was divided into two sections with equal weightage of the cess scores. The offset section involved review of records of newborn-care services at selected PHCs. The second section involved ascertainment and interview of the female parent for in-patient newborn treat iii newborns at each PHC. Delivery register of PHC was accessed and the last three recently delivered mothers were selected for interview.
National Guidelines for Immunization were used for cess of immunization services.[10,11] First section of assessment included Procedure observation of the immunization services during the immunization session (known as Mamta Divas in Gujarat) at PHCs for 5 children by systematic random sampling. Thus, a total of 60 children were observed for immunization services. The second section included assessment of common cold chain management at the selected PHCs.
As Vadodara district is i of those districts where trainings on Integrated Direction of Neonatal and Childhood Illness (IMNCI) has been implemented nosotros used IMNCI guidelines for cess of management practices for sick child at the selected PHCs.[12] Assessment involved review of IMNCI forms filled by MOs at the PHC during the calendar month preceding the visit. Five forms, each for Sick Young Baby (0–ii months) and Sick Kid (two months to 5 years) category, were assessed.
Growth monitoring was assessed by observation of the growth monitoring and counseling services provided by Female Health Workers (FHW) or Anganwadi workers for children up to ii years of age during the Mamta Divas session at studied PHCs. Guidelines on Growth Monitoring for Mamta Divas were used for assessment.[13] A total of sixty children, five from each of the 12 selected PHCs were observed.
Method of collection of relevant information for the procedure section included actual procedure observation, review of records and interview of the service providers and beneficiaries. During this entire exercise information technology was ensured that in that location was no disruption to the ongoing patient care services. All the observations for this assessment were made by single observer at all PHCs.
All the procedures followed were in accordance with the upstanding standards of the institutional ethical commission. All the staff members interviewed/observed for actual procedure of service provision were informed about the purpose of the study beforehand and their consent taken. The mothers interviewed in the study were explained about the purpose of the study and consent was taken before starting the interview.
For assessment of IMNCI the actual process ascertainment of direction of sick child could not be done and the assessment was based on review of records. The actual cess could have given more idea about the bodily practices for management of sick child.
The classical models of quality assessment also include assessment of outcomes which was not attempted in the current study every bit this would have entailed a large community based survey for community awareness and services utilization.
For immunization and growth monitoring assessment, actual service provision was observed which may have introduced participation bias as the providers beliefs may change in presence of an observer.
Results
The following are the findings of the Input and process assessment in the selected twelve 24 × 7 PHCs.
Input assessment
The obtained scores for various elements of Input department are shown in Table 1. Overall the mean obtained score was 65% of the maximum possible for the Input section.
Tabular array 1
Scores for the elements of input department
The chemical element of personnel and training received 56% score. 6 PHCs were manned by unmarried MBBS Medical Officer (MO), another two by AYUSH MOs whereas remaining four had both MBBS and AYUSH MO. Out of the total 12, only one-half of the PHCs had a MO (MBBS) available round the clock. Though all medical officers were trained in IMNCI, none were trained in essential new born care.
A paramedical person for emergency obstetric and newborn intendance was available at 11 of the 12 PHCs. Yet, a Staff Nurse was present at simply six of the PHCs, of which four had simply one staff nurse bachelor confronting the requirement of three. Moreover these staff nurses were also expected to perform duties other than RCH services. At the PHCs where there were no staff nurses, the obstetric and newborn intendance services were beingness provided with the assistance of FHWs, who were put on rotating Labor Room (LR) duties. At ii places male person candidates were appointed as Staff Nurses and did non contribute to service delivery as practically the LHV or FHWs were attending the deliveries at these places. With regard to training, only one PHC had paramedical staff trained in essential newborn care.
The obtained score for Infrastructure was at a moderate 65%. In this element, the score for cleanliness was 58% whereas that of the essential amenities was high at 94%. Other essential facilities scored 52% while the information and communication facilities scored 75%. With regard to the ship services at PHCs, information technology was institute that merely four of the 12 PHCs had their ain Ambulance and driver whereas the others were utilizing 108 services for sending the patient to the referral heart.
The element on Essential Protocols and Guidelines obtained simply 43% score which was lowest amid all elements of Inputs section. The IMNCI guidelines were bachelor at eight out of 12 PHCs. While the guidelines on Mamta Divas, immunization nautical chart, growth chart, besides as waste product management and mitt washing guidelines were bachelor at merely half to one tertiary of the PHCs. Essential new born intendance (ENBC) guideline was available at none of the PHCs.
The full equipments for growth monitoring were bachelor at seven out of 12 PHCs while consummate examination tray for IMNCI was available at only 1 PHC. All equipments for newborn-intendance were bachelor at 2 3rd of PHCs except radiant warmers which were bachelor at but two PHCs. Equipments for cold chain were available at about all of the centers. The overall score for equipments was higher at 74%.
The element on drugs and consumables obtained 86% score which was the highest score among all elements of Inputs section. All IMNCI drugs and vaccines were available at near all PHCs. Withal, only half of the PHCs had disinfectant available at the point of apply.
Process assessment
The obtained scores for four child health services are shown in Table 2. Overall the hateful obtained score was 55% for the procedure section.
Table two
Scores for services in procedure department
Newborn care
All PHCs had cleanliness maintained in labor room. The skilled omnipresence at birth was poor as merely four PHCs used detailed case sheets for newborn while none had records of APGAR score or nascence asphyxia direction. Delivery was conducted past nurses/FHWs in 75% instances and past trained dais in 22% instances. This was especially during the night fourth dimension. The postnatal stay of 48 hours was ensured at only four out of 12 PHCs.
Nigh 90% of the newborns received normal intendance such equally timely initiation and exclusive chest feeding, hypothermia prevention, string intendance and vaccination. Only half of the low nativity weight (LBW) newborns were explained about Kangaroo Mother Intendance and simply 11% newborns received communication on danger signs. Completely filled discharge card was given to but one fifth of the newborns.
Immunization
Immunization service obtained the maximum score among all 4 services. The cold chain management was appropriate at majority of the PHCs and the sessions. Merely right placement of vaccines in the Ice Lined Fridge was found at only 1 third and correct placement of icepacks in the Deep Freeze at none of the PHCs. Near 80–100% of the observed children received vaccination at appropriate age with correct dose, route and site. Correct segregation of biomedical waste was done at only 2 of the 12 sessions whereas chemical disinfection of the same was not done at whatever session. None of the sessions insisted on observing the child for half-an-hour for immediate adverse reactions. Not all mothers were given four key messages viz. the vaccine given, side effects, follow-up date and card safety.
Management of sick child
Although all the selected PHCs had IMNCI trained MOs, just i third of them were using IMNCI form for management of sick children. Review of these available forms of 'ill immature babe' category revealed that only 1 fourth of the forms were completely filled. Similarly less than half of these forms had correct nomenclature, treatment and advice mentioned in them. In the 'ill child' category, just one third forms were completely filled. Less than half of the forms had correct classification, handling and advice. Overall the services for direction of sick child obtained 41% of the maximum possible scores.
Growth monitoring
Only 5 out of 12 sessions offered growth monitoring to all the eligible children, the rest frequently missed out children especially siblings of the children who came for vaccination. Almost three fourth of children were correctly weighed and their weight correctly plotted amidst those who were offered growth monitoring. Nearly 80% of the mothers were informed regarding current weight of their kid; however, but 25% were told regarding their child's progress. The workers were observed for feeding cess and/or advice for children in yellow or cerise zone on growth chart. Near 80% of the children up to 6 months of age were advised about the breastfeeding frequency, however few were inquired on any difficulty in breastfeeding or advised sectional breastfeeding. Just one-half of the children in the age 6 months to 2 years were advised to continue breastfeeding till two years of age though almost all received advice on complementary feeding. Only one quaternary received communication on the correct amount, density and frequency of complementary feeds. Advice on active feeding and hygiene were never given. 'Check agreement' was likewise never practiced. Overall obtained score for growth monitoring was 52% of the maximum possible score.
Table iii summarizes the findings of the study in the class of strengths and weaknesses of the electric current practices in child health services in the studied PHCs.
Table three
Summary of findings
Discussion
With regard to the Inputs the highest scores were obtained for Drugs and Consumables followed by Equipments and Supplies. A similar report on child wellness services past Agarwal et al., also observed highest score for availability of drugs and vaccine at 90% followed past bones equipment at 61%.[6]
The component on availability of service provider and grooming had obtained a low score. It is of import that the 24-60 minutes PHCs have adequate numbers of MOs, staff nurses or ANMs posted at the PHC as well as staying within the bounds to ensure round the clock availability of the services. The guidelines on operationalizing 24 × 7 PHCs issued past Ministry of Health and Family Welfare also mentions that two MOs posted and working at the PHC is must.[7] Yet, our study finds that only one-half of the studied PHCs had a MO available circular the clock. The data on availability of wellness personnel at 24 × 7 PHCs in Bharat are non available separately. The data available from the National Facility Survey Study states that though 80% of the surveyed PHCs have at to the lowest degree one MO available only 64% of the PHCs had the MO staying at the PHC.[14] A recent study on quality assurance program in Gujarat found that 94% of the studied PHCs accept one MO available but only at 58% of the PHCs the MO stays at PHC.[fifteen] The alternative strategies have to be put in identify to ensure the availability of doctors at PHCs.
More than efforts are also needed to ensure availability of staff nurses at 24 × 7 PHCs. An important issue observed in this study was the practise of putting FHWs on rotating labor room duties. These FHWs are also expected to perform their routine duties at the sub-center apart from the LR duty. Technically they are also expected to conduct deliveries at their respected sub-centers. Hence, such an arrangement would serve only a short term purpose. Thus dedicated paramedical staff for care at nascence is necessary for 24 × 7 PHCs. Besides, technically at least 2 skilled attendants, a doctor and a paramedical staff, are needed at the fourth dimension of delivery wherein one is involved in care of the mother and the second attends to the newborn.
With regard to preparation of the available personnel the ENBC trainings are the need of the hr. Out of all the kid health service components the Newborn care is relatively new and the final to gain attention. The other components are in identify for quite some time and with the results of these efforts now the mortality due to these factors has come down with the neonatal bloodshed now contributing a major proportion of baby mortality. In this context it is of import that the forthcoming ENBC trainings preferentially train doctors and paramedics from the 24 × seven PHCs.
In our study the low score in Infrastructure facility was due to poor arrangements for biomedical waste management, non availability of oral rehydration therapy corners and lack of hand washing facility in labor room. Lack of emergency ship mechanism was also important to note. A functional emergency transportation arrangement to manage referrals at any time is an important requirement at 24 × 7 PHC. The practice of depending on EMRI ambulance service (popularly known by the name '108 ambulance' in Gujarat) for sending the patient from PHC to the referral center needs to be inverse. A '108 ambulance' is designed to transport a patient from field to the medical facility; we should not expect it to transport a patient from 1 medical facility to the referral center. Then having a defended transport facility of its ain and driver at 24 × 7 PHCs is very much essential.
The depression score in availability of essential protocols and guidelines is easy to meliorate as it requires simply one fourth dimension investment in making the guidelines available at the indicate of use; actually information technology likewise consumes fewer amounts of budgetary resource as compared to the other inputs.
With regard to the four services included in nowadays study, immunization and growth monitoring are oldest running programs whereas IMNCI and newborn care are relatively new entrants. This may explicate the highest scores immunization service has received in the nowadays study and other similar studies by Lal et al., and Agarwal et al., since improvements in service provision tin be expected in any program running for such a long fourth dimension.[4,6] Further immunization has received much attention, rightly so, amidst all child wellness services till now. But the low score in growth monitoring is specially important to note. For a program which is running since so long and yet at that place is so much of comeback which needs to be brought near in growth monitoring. Indeed achieving just coverage in terms of number of children weighed is not enough. It is rather wasteful use of resources if we fail to offer subsequent counseling to mothers where required.
As regards new born intendance, the lack of training of the staff in ENBC would explain non adherence to the guidelines, yet in absence of ENBC training the PHCs tin certainly make utilise of IMNCI guidelines and forms for in-patient newborn intendance. An of import ascertainment in this report about deliveries being conducted past trained belvedere at PHCs was besides corroborated by Raman et al.[sixteen] Ensuring adequate postnatal stay of the female parent and baby was also found to exist challenging in this study. It is especially important for LBW babies. But equally Raman et al., also observes in their study on 24 × 7 PHCs in Gujarat that most mothers were being discharged inside 4 hours.[xvi]
While earlier studies by Agarwal et al., and Lal et al., which also observes not and so good scores for services for management of sick child, were done before introduction of IMNCI.[iv,vi] The lacunae they observed were related to those points which required good communication with the care taker by the service provider for direction of under-five morbidities. In this report likewise it was observed that while the MOs invariably filled upwards the part of the IMNCI form on presenting morbidities; the breastfeeding assessment, data on vaccination and the engagement for side by side immunization also as temperature and weight tape were often missing. Agarwal et al., as well observed there was no exercise of recording weight for children with diarrhea and temperature for those with Astute Respiratory Infection.[6]
This result of communication and counseling is worth alluding every bit adequate accent on this was found to exist defective for all child health service components in this report. Advice about danger signs for newborn and Kangaroo Mother Care for depression nascency weight newborns, the four key letters for immunization, counseling component for growth monitoring were all trouble areas. It is important to note that this neglect of constructive communication was happening across the whole range of providers, from doctors to paramedical staff to the Anganwadi workers. The studies by Banerjee and Agarwal et al., both approve these findings.[6,17] Indeed, this component of communication with the female parent or care taker needs special attention by service providers.
Finally, the Input section, which deals with the structural attributes, fares meliorate than the process section. This finding was corroborated by Agarwal et al., in their study where the structural attributes were graded equally 'good' with overall 63% scores whereas procedure component was graded as 'average' with overall 43% scores.[vi] A study by Ehiri et al., on quality of child wellness services in Nigeria likewise institute that inadequacy in the quality of child health services in PHC was a product of failures in a range of quality measures viz. structure (lack of equipment and essential drugs), procedure failure (non-utilise of the national case management algorithm and lack of a protocol of systematic supervision of health workers).[18] The findings of the initial assessment in the pilot on quality assurance programme for RCH services in Ahamadnagar district of Maharashtra accept also shown similar results where many facilities scored good in the inputs cess, but were lagging backside in the process section.[19]
Ramani observes that in developing countries, there is an inherent importance given to structural components of quality, stemming from a long history of structural inadequacies.[20] Yet, even while accepting the importance of structural measurements, we need to understand the limitations of using structural measures alone as a proxy for measuring quality. For example, the Indian Public Wellness Standards largely addresses the structural lacunae such as the availability of medicines, equipment, etc. For the measurement of output component also we already have in place large calibration studies like National Family Wellness Survey. What is lacking is the focus on procedure every bit a quality mensurate.
Conclusion
Thus quality is non completely structure dependent. If nosotros employ merely structural measures of quality, at that place is a danger of blaming the lack of quality entirely on the lack of structure in spite of the existence of several deficiencies in the quality of care that are unrelated to structure (Inputs). The present study observes that the deficit is higher for process as compared to inputs. Hence adequate emphasis needs to be put on the process as well. Thus efforts to ameliorate the quality of kid health services, provided past PHCs in the study setting, should focus not simply on resource-intensive structural improvements, but also on cost-constructive measures that address actual commitment of services (process), especially the proper apply of guidelines for various services and a meaningful supervision to ensure adherence to the same.
Footnotes
Source of Back up: Nil.
Conflict of Interest: None declared.
References
i. National Program Implementation Plan RCH Phase II-Programme Document; 2005. Government of India, Ministry of Health and Family Welfare. [Google Scholar]
two. Gandhinagar: Ministry of Wellness and Family Welfare, Regime of Gujarat; 2006. Government of Gujarat. District Quality Assurance Programme for Reproductive Wellness Services, An operational manual. [Google Scholar]
iii. New Delhi: Ministry of Health and Family Welfare, Government of India; 2008. Government of India. Quality Assurance for Commune Reproductive and Kid Health Services in Public Wellness System, An Operational Manual. [Google Scholar]
4. Lal Southward, Kapoor S, Vashisht B, Punia Thou. Coverage and quality of maternal and child health services at subcentre level. Indian J Community Med. 2001;26:sixteen. [Google Scholar]
5. Rashmi, Vijaykumar B. Quality assessment of kid care services in primary health care settings of central karnataka (davangere district) Indian J Community Med. 2010;35:24–8. [PMC free article] [PubMed] [Google Scholar]
6. Agarwal Thou, Idris M, Ahmed Northward. Quality of Child Health Services at Chief Intendance Level (Rural vs Urban) in Lucknow District. Indian J Community Med. 2004;29:192–5. [Google Scholar]
7. NEW DELHI: Maternal Health Partitioning, Department of Family Welfare, Ministry of Health and Family Welfare; 2005. Govt of Republic of india. Guidelines for Operationalising a Chief Health Middle for Providing 24-Hr Delivery and Newborn Care Under RCH-Ii. [Google Scholar]
viii. Donabedian A. The quality of intendance: How can it be assessed? JAMA. 1988;260:1743–8. [PubMed] [Google Scholar]
9. New Delhi: Maternal Health Division, Section of Family unit Welfare, Ministry of Health and Family unit Welfare, Regime of India; 2005. Authorities of India. Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers. [Google Scholar]
10. New Delhi: Ministry of Wellness and Family Welfare, Authorities of Bharat; 2006. Government of India. Immunization Handbook for Health Workers. [Google Scholar]
eleven. New Delhi: Section of Family Welfare, Ministry of Health and Family unit Welfare, Authorities of India; 2009. Government of India. Immunization Handbook for Medical Officers. [Google Scholar]
12. New Delhi: Ministry building of Health and Family Welfare, Government of Republic of india; 2003. Government of India. Integrated Management of Neonatal and Childhood Illness. [Google Scholar]
13. Gandhinagar: Ministry of Health and Family unit Welfare, Government of Gujarat; 2006. Government of Gujarat, MAMTA Abhiyan Guidelines. [Google Scholar]
14. Mumbai: IIPS; 2007. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-iii), 2005–06. [Google Scholar]
fifteen. Kantharia S, Misra S, Patel D. Baroda: Deparment of Preventive and Social Medicine, Medical Higher; 2009. Assessment of quality assurance program of dept of health and family welfare - Gujarat country. [Google Scholar]
sixteen. Raman PS, Sharma B, Mavalankar D, Upadhyaya M. Assessing the regional and district capacity for operationalizing emergency obstetric care through first referral units in Gujarat Westward.P. No 2009-04-01. Indian Constitute of Direction, Ahmedabad April. 2009 [Google Scholar]
17. Banerjee B. Information, Education, and Communication Services in MCH Care Provided at an Urban Health Center. Indian J Community Med. 2009;34:298–300. [PMC free article] [PubMed] [Google Scholar]
18. Ehiri JE, Oyo-Ita AE, Anyanwu EC, Meremikwu MM, Ikpeme MB. Quality of child health services in primary wellness care facilities in south-e Nigeria. Kid Care Health Dev. 2005;31:181–91. [PubMed] [Google Scholar]
nineteen. Khan ME, Mishra A, Sharma V, Varkey LC. FRONTIERS Final Report. Washington DC: 2008. "Development of a Quality Assurance Procedure for Reproductive Health Services for Commune Public Health Systems: Implementation and Scale-up in the State of Gujarat" Population Quango April. [Google Scholar]
20. Ramani S. Can we transplant conceptual frameworks of healthcare quality evaluation from developed countries to developing countries? Indian J Customs Med. 2009;34:87–8. [PMC free article] [PubMed] [Google Scholar]
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535094/
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