Long-term outcomes of a paediatric quality improvement project in Central Asia: changes take time, time for a change

Quality health care is essential for reducing child mortality. A three-year World Health Organization (WHO) quality improvement (QI) project, implemented in the Kyrgyz Republic and Tajikistan between 2012 and 2014, aimed to enhance the quality of paediatric hospital care and thereby reduce child mortality. The intervention included training on international guidelines, provision of medicines, supplies, and equipment, and supportive supervision. This study assessed whether the project was successful in improving clinical practices in the long term in both countries.

We matched intervention hospitals with hospitals that did not participate in the QI project (control hospitals). We randomly selected medical records of children aged 2-59 months who were hospitalised with an acute respiratory infection or diarrhoea before the start of the QI project (2012), at its end (2015), and seven years after its completion (2021). We reviewed clinical practices from medical records to assess compliance with WHO standards for clinical care of children, which were emphasised in the project's training sessions.

In the Kyrgyz Republic, the quality of care improved in intervention hospitals between the start and the end of the QI project for all indicators except one: unnecessary hospitalisations, unnecessarily prolonged hospitalisations, and unnecessary antibiotic prescriptions decreased, while the use of pulse oximetry and oral rehydration salts (ORS) prescriptions increased. This improvement was sustained until 2021. In control hospitals, some improvements were also observed between 2012 and 2015, but these were less substantial and less sustained. The interventions had less effect in Tajikistan between 2012 and 2015, and the improvements were not always sustained until 2021: unnecessary antibiotic prescriptions decreased and ORS prescriptions increased by 2015 but reverted to baseline levels by 2021.

The QI project resulted in improvements in clinical practice in both countries, which were sustainable in the long term only in one country. The differences in long-term benefits may be attributable to factors within the health system environment. Issues related to health governance for, health financing, and health workforce were largely disregarded during the project's design and implementation, yet may be crucial for sustainability.