• clinical management
• developing countries
• district hospital
• quality improvement
• health care

Recent observational evidence suggests there is considerable scope for improving the quality of hospital care for severely ill children in many developing countries.¹ In a study of 21 hospitals in Asia and Africa that evaluated the management of 131 children, more than half were under treated or inappropriately treated with antibiotics, fluids, feeding, or oxygen. Inadequate triage and assessment, poor treatment, and insufficient monitoring may adversely affect the outcome of a significant proportion of hospitalised children, and result in unnecessary suffering or avoidable death for many children each year. In some other settings over-hospitalisation, over-diagnosis of severe illness, and over-medication has adverse consequences for health outcomes and in wasted health expenditure.^2–4 Until recently little attention was paid to these issues; the reasons are several. Firstly, because many more children in low income countries die before reaching any hospital for want of more basic interventions, such as measles vaccine or oral rehydration solution, and the legitimate concern that promoting hospitals may detract from primary level or community based care. Secondly, confronting potentially avoidable deaths or suffering in children is upsetting, to communities, to hospitals, and to health workers who struggle to provide the highest level of care they can. Furthermore, in most countries academic thought and energy has been predominantly directed towards clinical problems seen in tertiary university hospitals, with inadequate consideration of the health system problems in peripheral hospitals, which are often understaffed, poorly equipped and maintained, and with little or no ongoing staff education. Also, until recently there has been little evidence that outcomes could be improved without very major investment in staffing and technology.

While there are examples of inequitable and inefficient resource allocation where tertiary hospitals have consumed disproportionate resources and starved primary health care, good quality …