How a district hospital in Kara-Suu turned around to cut child mortality

Kyrgyzstan ranks #79 out of 184 countries on neonatal mortality rate. Simple solutions save lives!

By Sven G. Simonsen
resuscitation unit
UNICEF/Sven Simonsen

19 February 2018

‘The baby you saw…’ – Dr.  Shavkat Tadjibaev gestures towards the resuscitation room that he has just shown us – ‘the way things were three years ago, he most likely would not have lived this long. But now he is calm, he is breathing,  we can tell he is recovering.’

Dr. Tadjibaev is a pediatrician resuscitator at Kara-Suu Children’s Territorial Hospital in Kyrgyzstan’s southern Osh province. This hospital serves a population that is predominantly ethnic Uzbek. Kara-Suu was among the districts most affected by the ethnic unrest that played out in Kyrgyzstan in 2010. Dr. Tadjibaev is relating a story that is deeply personal. It is also a story of how, in a short time, the  care of severely ill children across the country has been sharply improved.

 

Dramatic beginning

The story began in the most dramatic way, on a spring day in 2013. Dr. Tadjibaev was on duty as a four-month old baby boy sick with diarrhea had fallen into a coma. The medical staff had no means of helping the child, and he could not be transported to the provincial hospital, even though it was only 20 minutes away.

ambulance
UNICEF Kyrgyzstan/2017/Chilpon Imanalieva
The drama that set off a series of hospital reforms: in 2013, a four-month old baby boy in a coma is transported from Kara-Suu to the provincial hospital in Osh city.

‘The child was dying, but all we could do was observe his condition’, Dr. Tadjibaev explains.

However, on this particular day, two senior doctors representing UNICEF and the Ministry of Health were visiting the hospital from Bishkek . They contacted the provincial hospital, and insisted that a fully equipped ambulance be sent for the child. The ambulance came, and the boy was treated in Osh.

‘When we visited the next day, he was conscious and smiling',

says Cholpon Imanalieva, Chief of Health at UNICEF Kyrgyzstan.

What happened that day, however, was only the beginning of a bigger story. Because the incident had highlighted a series of weaknesses in hospitals’ care for severely ill children, that every year caused in many deaths that could have been prevented.

At Kara-Suu, until a few years ago, the situation was ‘very bad’, says Dr. Gulmira Kalbaeva, the hospital’s director, who started working here seven years ago.

‘The mortality rate was very high. We saw 40-43 children die here every year. Twenty or more died from pneumonia alone.’

 

UNICEF initiatives

The causes were multiple: it was about lack of equipment, lack of training, flawed routines, and poor cooperation between hospitals. Each one of the causes would be addressed in a series of UNICEF initiatives, funded by the Government of Japan,  that followed.

CPAP
UNICEF Kyrgyzstan/2017/Vlad Ushakov
Thirty-four hospitals in Kyrgyzstan – including Kara-Suu Children’s Territorial Hospital – have received CPAP assisted breathing machines from UNICEF.

The incident had highlighted the lack of agreed-upon standards for how doctors should respond to various medical emergencies. The consequences could be dire:

'It was chaotic sometimes. Staff members did not understand each other, every doctor had his own way of treatment', Dr. Tadjibaev says.

UNICEF, with the Ministry of Health, initiated a process to formulate for the first time national standards for child resuscitation for four of the most common conditions; these have recently been approved.

'The standards provides clear mechanisms, which saves us time. Now, we actually have only half the number of children we used to have in resuscitation, because we respond more adequately to each case’,

Dr. Tadjibaev says.

 

Trained as teams

In parallel, UNICEF initiated broad-based training of child resuscitators and other medical staff at hospitals nationwide. In 2015, UNICEF brought a team of specialists from Lithuania to train all child resuscitators in PALS – paediatric advanced life support.

A subsequent assessment has shown that rescuscitators in the country who have been trained in PALS perform 30 per cent better than those who have not.

Life support has also recently become part of the national curriculum for post-graduate paediatric education.

All medical staff at Kara-Suu have undergone various trainings to improve skills:

doctors
UNICEF Kyrgyzstan/2017/Sven Simonsen
'We like the way UNICEF conducts trainings', says Dr. Kalbaeva, the director: 'The trainings are practical, to the point, and they are followed up with supervising visits to make sure that the news skills are being used.'

'One important aspect of the training is that doctors were trained together with the nurses, on how to act together as a team', Dr. Tadjibaev says. 'Before, nurses could not provide help for a child in an emergency; they were scared and did not know how to act. But now they can step in if the doctor is away.'

 

Better equipment, referrals when required

A more adequate response is also enabled by better equipment. Until recently, the resuscitation room at the hospital was practically devoid of functioning equipment. Now, it has three beds each fully equipped with life-saving equipment. In particular, Kara-Suu is one of 34 hospitals in the country that has received CPAP machines – which help children breathe, in a non-intrusive way – from UNICEF.

Dr.Tajibaev
UNICEF/S.Simonsen
Dr. Shavkat Tadjibaev at the hospital’s resuscitation room, which now has three beds each fully equipped with life-saving equipment.

Finally, UNICEF has also helped prepare standards for referral of severely ill children, to ensure that transport in well-equipped ambulances is provided without delay when necessary – and that the larger hospitals are prepared to receive.

Up until just three years ago, every year some 15-20 children died while being transported by taxi from Kara-Suu villages to the provincial hospital in Osh. In 2013, out of 27 children sent to Osh from local health centers or by their families, as many as 19 died on the road or during the first 3 hours of hospitalization. Today, with ambulance transport and a referral system that works, this happens perhaps once in a year.

 

‘I can sleep well at night’

The mortality rate is also dramatically lower at Kara-Suu hospital itself: whereas 6-7 years ago, 20-25 children died from pneumonia every year, that number was down to 5 in 2015, and only 2 in 2016.

The child that Dr. Tadjibaev pointed to earlier in our conversation has been very sick with pneumonia. Its prognosis is good now – much better than it would have been just a few years ago.

Asked what this improvement means to him personally, Dr. Tadjibaev answers:

'Before, when  child died, I felt as if I had not saved it even though I should have been able to. That is a very, very bad feeling to live with', he says.

'But now I can sleep well at night.'