Table 3

Gaps in QoC identified and proposed solutions agreed

Area evaluated	Priority problems observed	Proposed solutions
1. Physical structure, staff, water and power	Hospital level Lack of specialised doctors (1 doctor for 28 beds) and nurses (one single nurse for the night shifts) and high turnover among nurses. Lack of running water in most taps. Lack of basic services for hygiene of patients and staff. Irregular power supply/no efficient back up system (lamps broken). Serious lack of maintenance of power sources with impossibility to use available equipment for reanimation (aspirator and oxygen concentrator). Health centre (HC) Lack of running water in one HC. Lack of staff in some HCs. Serious deficiencies in the emergency rooms.	1. Advocacy with funding partners to ensure funds for physical restructuring of the ward (water, power and toilets). 2. Develop curricular training specific to health workers involved in management of malnourished children. 3. Employ one additional doctor at hospital level. 4. Reorganise nurses’ shifts to ensure presence of at least two nurses at night. 5. Reorganise the emergency room. 6. When there is lack of running water, organise appropriate receptacles for water and use hand disinfectant.
2. Statistics and medical records	Serious inconsistencies and frequent lack of data in the official registers and medical forms. Lack of adequate knowledge and use of existing instruments and tools for statistical reporting among the staff. Inadequate systems for statistical reporting at hospital level, with inconsistencies in annual reports.	7. Strengthen training on existing statistical reporting tools, as for the national guidelines. 8. Supportive supervision with periodical audits. 9. M&E as a priority.
3. Pharmacy and medicine availability	Lack of an essential drug list. No temperature and humidity control in the pharmacy store. At hospital lack of mebendazole, phenobarbital, zinc, potassium, oral quinine oral and some drugs found expired. At HC lack of drugs for emergency treatment and other essential drugs. Lack of stable supplies of therapeutic foods: F75, F100, Resomal, MultiMix, Plumpy Nut, CSB and water with sugar.	10. Develop a list of essential drugs. 11. On the job supportive supervision on pharmacy management. 12. Compulsory preparation of water with sugar to be administered to each child at entry.
4. Equipment and supplies	Serious lack of maintenance of essential equipment (eg, scales). Serious lack of appropriate use of existing equipment (Ambu bag, length measuring board and MUAC tape). Some lack in availability of equipment (scales for children). Breakdown in supplies of drugs and foods.	13. Create an effective system for technical maintenance (will need external support). 14. Procure certain basic equipment.
5. Laboratory support	Quality was very heterogeneous among different services.	15. Strengthen the lab quality control systems.
6. Layout of the ward	One single room for all children with SAM (no separation for TB cases and other infectious diseases cases such as salmonellas).	16. Consider changing the ward layout (will need external support).
7. Food preparation	Serious mistakes in preparation of F75 and F100 not according to the recipe (450 Kcal instead of 750 Kcal). Some problems in food storage.	17. On-the-job training and supportive supervision. 18. Presence of a nutritionist.
8.Case identification, triage and emergency treatment	Low number of children identified in respect of expected prevalence of malnutrition. No triage implemented at HC level and serious lack in emergency treatment.	19. Train all personnel in triage and emergency treatment. 20. Strengthen collaboration with activists for case finding in the community.
9. Case management	Lack of adequate knowledge and use of existing guidelines and tools (job aids, tables and so on). Lack of adherence to existing guidelines and frequent inconsistencies in case management.	21. Develop a ‘plan of work’ for each health worker. 22. Strengthen training on guidelines of management of SAM and MAM. 23. Print wall posters with clinical algorithms and other job aids. 24. Establish a system of routine audit of case managment.
10.Monitoring and follow-up	Serious lack of adequate monitoring of hospitalised children, especially at night and during weekends	25. On the job training and supervisions. 26. Establish a system of routine audit M&E.
11. Discharge and postdischarge follow-up.	Lack of communication resulting in lack of continuity of care among services.	27. Strengthen communication systems (consider pilot use of mobile phones).
12. Infection prevention	Existing guidelines are not disseminated, implemented and monitored. Audit system not pointing out real problems.	28. Disseminate existing guidelines. 29. Strengthen the existing system of audits M&E.
13. Guidelines and training	Most staff were trained, but in several cases, this was not effective. Lack of monitoring and of supportive supervision.	30. On-the-job training and supervision. 31. Establish a system of routine audit M&E.
14. Audit systems	Serious lack of audits systems.	32. Establish effective systems of routine audit with a real problem-solving attitude. 33. Disseminate a culture against ‘hiding of problems’.
15. Access to hospital care and continuity of care	Serious deficiencies in communication among services, with gaps in continuity of care.	34. Strengthen collaboration with activists for case finding. 35. Develop alternative methods for community mobilisation on malnutrition, using different platforms (ie, activists, the health committees, ‘agents for health preventions’). 36. Strengthen communication systems (consider pilot use of mobile phones).
16. Patients’ rights	Substantially substandard.	37. Disseminate the chart on patient rights. 38. Supportive supervision and periodical audit M&E.

CSB, corn and soy blended flour; F75, Formula F75 (this is a special food for children with SAM); F100, Formula F100 (this is a specially food for children with SAM); HC, health centre;MAM, moderate acute malnutrition ; M&E, monitoring and evaluation; MUAC, mid-upper arm circumference; QoC, quality of care; SAM, severe acute malnutrition; TB, tuberculosis.