Quality of nutrition services in primary health care facilities: Implications for integrating nutrition into the health system in Bangladesh

BackgroundIn 2011, the Bangladesh Government introduced the National Nutrition Services (NNS) by leveraging the existing health infrastructure to deliver nutrition services to pregnant woman and children. This study examined the quality of nutrition services provided during antenatal care (ANC) and management of sick children younger than five years.MethodsService delivery quality was assessed across three dimensions; structural readiness, process and outcome. Structural readiness was assessed by observing the presence of equipment, guidelines and register/reporting forms in ANC rooms and consulting areas for sick children at 37 primary healthcare facilities in 12 sub-districts. In addition, the training and knowledge relevant to nutrition service delivery of 95 healthcare providers was determined. The process of nutrition service delivery was assessed by observing 381 ANC visits and 826 sick children consultations. Satisfaction with the service was the outcome and was determined by interviewing 541 mothers/caregivers of sick children.ResultsStructural readiness to provide nutrition services was higher for ANC compared to management of sick children; 73% of ANC rooms had >5 of the 13 essential items while only 13% of the designated areas for management of sick children had >5 of the 13 essential items. One in five (19%) healthcare providers had received nutrition training through the NNS. Delivery of the nutrition services was poor: ConclusionsStrengthening the provision of equipment and increasing the coverage of training are imperative to improve nutrition services. Inherent barriers to implementing nutrition services in primary health care, especially high caseloads during the management of sick under-five children, should be considered to identify alternative and appropriate service delivery platforms before nationwide scale up.

背景 2011年，孟加拉国政府依托现有医疗卫生基础设施，推出国家营养服务（National Nutrition Services, NNS），为孕妇与儿童提供营养服务。本研究针对产前保健（Antenatal Care, ANC）过程中提供的营养服务，以及5岁以下患病儿童的诊疗管理服务质量展开评估。
方法 本研究从结构准备度、服务流程与服务结局三个维度对营养服务的供给质量进行评估。结构准备度的评估方式为：在12个乡级行政区的37所基层医疗卫生机构中，检查产前保健诊室与患病儿童接诊区域内的设备、诊疗指南以及登记本与报告表单的配备情况。此外，本研究还对95名医疗卫生服务提供者的营养服务供给相关培训经历与知识水平进行了调研。通过实地观察381例产前保健就诊流程与826例患病儿童接诊流程，对营养服务的供给流程进行评估。以服务满意度作为服务结局指标，通过访谈541名患病儿童的母亲/照料者完成相关数据采集。
结果 相较于5岁以下患病儿童的诊疗管理服务，产前保健的营养服务供给结构准备度更高：73%的产前保健诊室配备了13项核心物资中的5项及以上，而仅13%的患病儿童接诊专区配备了5项及以上的13项核心物资。仅有五分之一（19%）的医疗卫生服务提供者接受过国家营养服务计划组织的营养培训。本次调研显示营养服务的供给质量欠佳。
结论 加强设备配置、扩大培训覆盖范围，是提升营养服务质量的必要举措。在基层医疗卫生机构开展营养服务存在固有障碍，尤其是5岁以下患病儿童诊疗管理过程中接诊量过高的问题；因此在全国范围内推广该服务前，需明确替代方案与适配的服务供给模式。